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eJOURNAL OF THE INTERNATIONAL CHILD AND YOUTH CARE NETWORK (CYC-Net) – ISSN 1605-7406

ISSUE 123 MAY 2009 •  CONTENTS •  HOME PAGE

PRACTICE

Ritual of Inclusion: An approach to extreme uncontrolled behaviour in children and young adolescents

Michael White

Abstract: This paper presents a ritual approach to extreme uncontrolled behaviour in children and young adolescents that is guided by “time-in” as a metaphor for treatment. The successful introduction of a new “frame” for the uncontrolled behaviour is emphasized, one that disrupts the habitual but impotent attempts of family members to address this behaviour, attempts that are so reinforcing of “time-out” in relationships. Details of the approach are described within the context of the three phases of Van Gennep’s (1960) “rite of passage.”

Introduction
This article represents an account of some work that I developed many years ago. This work was profoundly helpful to families in states of crisis with children and adolescents whose lives appeared to be set on courses of self-destruction and on isolation from others, and where there existed a high risk of physical injury to family members. Often, particularly in situations where this risk had been demonstrated, the “Ritual of Inclusion” provided the only available recourse to an action that mitigated further institutional placements and separations. And yet, despite this, I feel entirely ambivalent about the republication of this article in this journal, and, in many ways regret ever having written the piece in the first place.

Why this regret? Well, for a description of such a significant intervention, the discussion in this article is nowhere near extensive enough; there are far too many gaps in the account of this work, and far too much is assumed. Among other things, I regret not drawing attention to:

  1. The potential for this ritual to be taken into the service of oppression; the many ways that this work might be misused in the reproduction of tyranny in the lives of children and young adolescents.

  2. The extent to which this ritual was introduced in those situations where there had been many, many, previous interventions that had failed to bring about any desired outcomes whatsoever.

  3. The fact that most of the children and adolescents referred to in this discussion were “radically disconnected” from others, having had experiences of multiple and traumatic separations for a variety of reasons, and the fact that a great number of them had spent time in various institutions and in foster placements.

  4. The imperative that I give to the determination of whether or not the child/adolescent’s living context is one in which s/he is being subject to abuse in any of its forms, and whether or not s/he has been subject to historical abuses that have gone undetected. The footnote about the abuse hypothesis should be taken into the text, and the discussion of this extended to include details of the routine investigation of this hypothesis in all work with children and adolescents.

  5. The preparatory work that often needs to be done with parents or parent figures to establish the goal of inclusion as a priority and as a commitment in their interactions with the child/adolescent, and to satisfactorily address and resolve any blocks to their engagement in emotionally intimate and nurturing interactions with the child/adolescent.

  6. The importance of consulting the child/adolescent about the contexts of any abuses that s/he may have been subject to, clarifying the distinction between the context and the structure of the Ritual of Inclusion and these contexts of abuse, and, if necessary, modifying the ritual so as to emphasize this distinction.

  7. The priority that is given to the acknowledgement of the child/adolescent’s self-knowledge during the reincorporation phase of the ritual. At this time, very considerable attention is given to the articulation of, and the honouring of, the child/adolescent’s own account of their preferred desires, purposes, plans, goals, hopes, and so on, and to the identification of those qualities and skills possessed by the child/adolescent that can be put into the service of these desires, purposes, plans, goals, and hopes.

  8. The extent to which the Ritual of Inclusion, in putting young people “in touch” with others, and others with them, makes them far more able to talk of the separations and abuses to which they have been subject, and to express their experiences of these in new ways that have constructive rather than destructive effects in their lives and on their relationships.

It is now many years since I have engaged families in the formal Ritual of Inclusion. This is principally due to the fact that I have, over the last decade or so, developed other options in this work with “radically disconnected” young people and their families; options that assist young people to step into “inclusion projects,” and to step away from careers of self-destruction.
In stating this, it is not my intention to abandon the Ritual of Inclusion. I have no doubt that there will be future occasions when I run up against the limits of other inclusion practices, and upon which I will again share this proposal with families. On these occasions I do expect that the introduction of the Ritual of Inclusion as an option will clarify, for family members, the nature of the central task, and I have no doubt that this will stimulate thought on new and unique options for accomplishing this.

The Ritual of Inclusion is an approach to extreme, uncontrolled behaviour in children and young adolescents, one that I have developed over many years. Although it was originally called the “Firm-Holding Technique,” I was never comfortable with that description.

The approach entails a lot more than technique. When utilizing and teaching it, I always place a very great first emphasis on the development and introduction of a new frame for the uncontrolled behaviour, one that enables family members, and members of the health/welfare system, to orient themselves differently in relation to such behaviour. Upon reflecting on this work, and when watching video tapes of first and subsequent sessions with families, as well as follow-up interview, what always appears most important to the longer-term beneficial outcome of the approach is the extent to which family members have been able to “reframe” the uncontrolled behaviour. When applied outside of the context of this new frame, I am sure that the method described in this paper could serve to oppress, and for that reason I have never been prepared to give brief consultations on it.

Several years ago, when I was teaching the approach at a workshop, David Epston1 identified in it what he believed to be various aspects of a ritual process. He reviewed Van Gennep’s (1960) description of that class of ritual called “rite of passage,” emphasizing the phases of separation, liminality, and reincorporation, and suggested that I rename it the “Ritual of Inclusion.” I found the identity both intriguing and striking, and embraced his suggested title as a more adequate description of the approach.

The Ritual of Inclusion includes a phase of physical restraint and some readers are likely to feel uneasy about this aspect. I would argue however, that, properly done, the ritual leads to a sense of personal empowerment for all family members.

Although there are other approaches reported in the literature that utilize physical restraint (e.g., Friedman, Dreizen, Harris, Schoen and Shulman, 1978), these emphasize a very different frame for uncontrolled behaviour, and the development of the Ritual of Inclusion was not informed by them.

The families
When frustrated, the children and young adolescents in the families for whom this ritual was developed, invariably tantrum, often leaving a trail of destruction that can include broken doors, windows, and bruised parents. These young people seem to have a very great difficulty in finding a constructive direction for their lives, and often are more attracted to a “failure lifestyle” than towards a more successful one. The negative reaction that they usually have to praise is one of the many examples that can be cited to support this conclusion. It is usual to find that, over the years, various diagnoses have been applied to these young people, diagnoses which include hyperactivity, conduct disorder, and sociopathy.

Many of these families habitually seek professional help for the uncontrolled behaviour. Most describe a history in which the problem has defeated all advice received. Although the parents of these families are usually familiar with time-out procedures for dealing with behaviour problems, they commonly report these procedures to be reinforcing of the uncontrolled behaviour, provoking of further episodes of destructive behaviour that can include physical injury, and running away.2

The histories presented by these families also suggested that repeated attempts to deal with the problem by removing the young person to foster homes, hospitals and other institutions only reinforced the uncontrolled behaviour over time.3

When assessing the experience of children and parents in these families, it becomes apparent that the feeling of “time-out” in relationships is a common feature. The parents usually report a longstanding experience of rejection from their child. They can present examples of this rejection from an early stage in the child’s life, examples that range from breast-refusal to early difficulties in their attempts to “get through” to the child. Pursuing this theme of rejection usually establishes that the parents believe that the child is entirely insensitive, out of touch with, and disinterested in their suffering.

When relating their failed attempts to solve the problem, the parents report a sense of impotence in not knowing what further to do. They feel lost and helpless in relation to the uncontrolled behaviour. Many disclose that, while on the one hand they experience a profound sense of inadequacy and guilt, on the other, they experience great anger associated with a perception that the child is wilful and has negative intent towards them. When these circumstances present, not only does the child seem out of touch with the parents, but the parents also seem out of touch with each other and the child, and isolated from other parents whom they believe cope so well with the task of parenting. For these parents, survival becomes a matter of “it’s either him/her or us.”

When the young person’s account of life and family is accessible, they usually report a similar experience in relation to other family members.4 They believe that they are bad and hopeless, and feel rejected, impotent and despairing. They are angry about the “unfairness” that they believe to be perpetrated by their parents (and the world) and become convinced that others have negative intent toward them. They believe their parents to be wilful, and survival becomes a matter of “it’s either them or me.” These are isolated young people, at a loss and out of touch with others. They appear unable to perceive the experience of others and, at the same time, feel that their experience is not perceived by others.

It is clearly apparent that the attempted solutions that are activated by the “it’s either him/her or us” and the “it’s either them or me” positions further reinforce time-out in relationships and contribute more to the theory of negative intent and to the survival of the uncontrolled behaviour. Despite this, these attempted solutions appear compelling. Family members feel unable to stop doing what they know doesn’t work. Elsewhere I have employed a cybernetic metaphor to explain the perpetuation of such conditions and have referred to second cybernetics and vicious cycles when discussing their development (White, 1984).

Time-out versus time-in
This analysis of the context of extreme, uncontrolled behaviour in children and young adolescents, led me to contemplate the appropriateness of “time-in” procedures. I believe that the selection of “time-in” as a metaphor for treatment was reinforced by my impression that a disproportionate number of children that were referred to me, at the outset of the development of this approach had histories of separation from their families and these histories often included prematurity, fostering and institutionalization.

The approach outlined in this paper was spurred by this contemplation and a cybernetic analysis of the content of extreme uncontrolled behaviour, and it includes details of various developments that have taken place over some years, details that I believe have rendered this method more reliable. Many of these details have been generated through a trial-and-error learning process, from discoveries made when participating with families in the application of the approach. Video taped analysis of interviews and the comments of family members on follow-up have been particularly valuable in this learning process. The approach is now routinely introduced to families and health/welfare professionals as the Ritual of Inclusion. To reinforce this description of the approach, and for ease of discussion, I have organized the paper under the three phases of that class of ritual referred to as a “rite of passage.” These phases are: separation, liminality, and reincorporation (Van Gennep, 1960; Turner, 1969).

Separation phase
During the separation phase, the therapist invites family members to join in the construction of a new description of the problem, one that introduces an alternative frame for the uncontrolled behaviour. This separates the family members from their presenting definition of the problem and detaches them from their habitual attempts to solve the problem, attempts that are so reinforcing of the problem. This is also the joining stage, during which the therapist asks questions that assist family members to maximize the expression of their experience of oppression and despair, questions that assist the therapist to gain an approximate understanding of their experience.

Questions requiring family members to objectify, externalize, and even personify the problem, are very effective in the therapist-family member co-construction of a new definition of the problem, a definition that challenges a “wilful” construction and suggests instead a “will-less” construction. In response to these questions, family members experience that they are all in it together, and become detached from the “it’s either him/her or us” and the “it’s either them or me” attempted solutions.

The family’s usual term of reference for the uncontrolled behaviour is ascertained.5 Family members are then asked to provide details about the various attempted solutions that the problem has beaten, and to describe the extent of the problem’s influence in their lives and relationships. I usually begin by taking down details regarding the effect of the uncontrolled behaviour on the young person’s present life and relationships, and its expected effect on his/her future. Usually the information derived includes details about insensitivity, and, in response, the therapist can ask for examples that provide the clearest evidence that the young person is “out of touch” and “at a loss.”

When the extent of the young person’s “domination” by the tantrums is established, the therapist can then ask other family members about the effect of the uncontrolled behaviour on their lives. How do the tantrums make it difficult for them to get in touch with the young person? How do the tantrums have an isolating effect on other members of the family as well? How does the oppression of the tantrums invite hopelessness and despair? Further discussion can centre around the likely consequences for all should the tantrums become more extensive and the out-of-touchness and “brick-wall” syndrome more complete.

As part of the separation phase, the therapist also invites the construction of a second description that presents family members with the possibility of an escape from the state of affairs that has been so oppressive to them.6 The idea of moving beyond this state of affairs can then be entertained.

The construction of this second description entails the introduction of questions that bring forth the influence of family members in the life of the uncontrolled behaviour. Although difficult for family members to select out, there will always be information available that contradicts the view that all is lost, facts that can provide evidence that the lives and relationships of family members have not been totally claimed by the tantrums. These questions introduce the idea of the family members’ competence in the face of the tantrums.

Collecting information about instances of the young person’s escape from the tantrums on occasions when s/he could have submitted to them, provide a good starting point. As examples of these incidents do not readily occur to family members in the first place, the therapist is initially required to be active in the selecting out of this new description. For example, the therapist can be surprised at the ability of the young person to defy the tantrums and threaten their influence by attending the meeting. Observations can be made about the many ways that the tantrums could have made sure that the meeting didn’t happen if the young person had submitted to their oppression.

Instances in which other family members have been able to escape the usual influence of the tantrums on their lives and relationships can also be selected out. For example, family members can be questioned as to how, under the circumstances, they have been able to rebel against the despair caused by the tantrums and keep alive the hope that things could be different. Once this second description is initiated in this way, family members are usually able to elaborate on it with further examples of escape from the tantrums’ influence, examples that did not previously occur to them.

A dilemma is then raised for family members by juxtaposing (1) timeout and time-in, and (2) the oppression of the tantrums and liberation from this oppression. These themes are then linked via questioning. For example: “Do you feel more attracted to time-out and oppression by the tantrums, or do you think that time-in and liberation personally suits you more?” This dilemma can then be intensified by further questioning.

Usually family members argue to oppose time-out and the oppression of the tantrums. At this stage the therapist informs them that s/he knows of an approach that will enable them to get more in touch with each other, and thus promote sensitivity to each other’s thoughts and feelings, an approach that will assist them to escape the oppression of the tantrums. Although the beneficial aspects of this approach will be experienced by all, it will be particularly helpful in assisting the young person to cope with choice in their life and will enable them to forge a more constructive direction. It will enable family members to challenge the pervasive experience of time-out in relationships and, as well, defeat the uncontrolled behaviour.

The therapist then prepares the family members for the disruption that will accompany the transition or liminal phase. Parents are told that if they are successful with the ritual then they cannot fail in saving the young person’s future and in the salvaging of relationships in the family. However, it is asserted that they will not be ready for success unless they are willing and prepared to cope with the discomfort and disruption that can be associated with the ritual. If they minimize the task at hand or minimize the commitment that they are taking on, then the ritual will not be helpful to them.

Liminal phase
The liminal phase is a period of transition. Although when referring to this phase, therapists and family members usually describe it as “the ritual,” it is in fact the middle stage of the ritual, between separation and reincorporation. The liminal phase is structured to occasion both the suspension of the usual temporal punctuation of events by establishing time apart from clock time, and the disruption of the habitual orientation and organization of family members in relation to events. As there is so much uncertainty for family members associated with this phase, a map of the probable experiences that they will undergo is provided. This map gives advance notice of the likelihood of an affect-laden experience that I term a “crisis of intimacy,” followed by an experience for family members that could be described as a sense of communitas, a sense of belonging.7

There are a number of details that are important in the structuring of the liminal phase. These details are introduced to family members in the form of instructions and notes, and family members are invited to record them. Time and again, when consulted about a ritual8 that hasn’t had the desired outcome, I discover that some of these details have been neglected.

Instructions and notes

  1. The tantrums will not get better of their own accord. To reinforce this it may be useful for the therapist to summarize again those solutions that have been attempted and have failed.

  2. The ritual has nothing whatsoever to do with those solutions that have failed, and has no relation to punishment, reasoning or medication.

  3. Time, effort, and perseverance, are necessary. The therapist can give examples of what has been required of other families in terms of these aspects9. It should be stressed that there are no soft options and that the choice that parents face is either a large effort in the short term or chronic fatigue in the longer term.

  4. A considerable improvement in the state of affairs will be experienced after the initial sessions, followed by a “hiccup” or relapse before a more longstanding improvement is achieved. This hiccup will be evidence of progress.

  5. The structuring of time apart from clock time is required. The parents are told that they should take the steps necessary to prevent the ritual from being measured in clock time. All references to clock time should be removed. This includes clocks, watches, radios, etc. If the ritual is held during the day, blinds should be pulled.

  6. There should be no interruptions whatsoever during the ritual. It is suggested that the phone be taken off the hook and that arrangements be made for other children to be cared for elsewhere.

  7. At least two adults are always required to be present to carry out the ritual. Preferably this should be the young person’s parents, and where possible, friends of the parents and/or relatives should be involved as well. The ritual should never be undertaken by one parent alone. In the case of sole parents who are isolated, the therapist should either arrange to join them in the ritual or involve community workers who are familiar with the approach.10

  8. The experience will be difficult for the adults and they will be required to work together to support each other. Two roles are prescribed, that of the “insider” and that of the “outsider.” The insider is required to undertake the physical restraint of the young person, and the outsider is to support and nurture the insider, helping them to process the various feelings that they will undergo. The adults can alternate roles and assist in the maintenance of the physical restraint.

  9. There is no requirement for the ritual to be instituted at the time of the tantrum. Instead, parents are advised to continue to do what they would usually do in response to a tantrum. Tantrums mostly occur in the presence of the more defeated parent and, at these times, this parent’s feelings are also running high. To attempt to institute the ritual under these conditions can only be complicating. However, the parents should try to match the number of applications of the ritual to the number of episodes of tantrum behaviour. Rituals should always be planned in advance at a time when parents can be free of other commitments. Where tantrums are frequent and the family’s schedule busy, it will not be possible to undertake the ritual more than once or twice per week. The parents can decide to group a number of these tantrums together and match them with one ritual. Matching is necessary so that a decrease in the frequency of episodes of tantrum behaviour can be associated with a decrease in the frequency of the application of rituals.

  10. Opportunities to introduce the ritual should not be avoided. Parents are encouraged to establish conditions that they know, from past experience, will trigger off tantrums. This instruction prescribes a confrontative posture that is the reverse of the avoidance posture that parents have usually evolved.

  11. The ritual will not be negatively reinforcing to intimacy. Nor will it be oppressive. Rather, it triggers a “crisis of intimacy” and the parents will notice a tendency for the young person to seek them out more often for physical closeness, for “belongingness experiences.” They will also notice that, rather than oppressing, the ritual will establish in the young person a greater capacity for dealing responsibly with choice.

  12. The young person is not to be given advanced warning of the introduction of the ritual even though it has been planned in advance.

  13. Once commenced, the ritual must be persisted with through to the end. If parents have strong doubts about their resolve to persist, it would be better that they do not initiate this approach, since to desist would only serve to reinforce the experience of oppression by the tantrums and time-out in relationships.

  14. Parents will not need advice about when the ritual is completed, about when they can cease the physical restraint. Parents intuitively know when the ritual is complete.

  15. A small “treat” should be scheduled for the completion of the ritual, one that can be shared by all those involved.

  16. Family members should telephone the therapist after the first ritual so that s/he might assist them to process their experience of it.

  17. Following the introduction of the first ritual, the parents are to keep a log of all the changes they notice in the young person’s behaviour and in their relationship with him/her. This log is then reviewed with the therapist at the next interview.

Family members are then given a map of the likely stages of the young person’s experience. They are told that this is a very general map, that there will be blurring of stages, that exact prediction is impossible, and that no two families have identical experiences during this stage. The therapist can make other comments that lend further to the atmosphere of uncertainty and excitement.

Map of stages
This map was derived from the reviewing of video tapes of the ritual process in my room and from reports of family members. On reflection, I consider these stages similar to those of grief, and perhaps my knowledge of the grief process in some way informed my observations of this ritual process.

  1. Quiet sufferance: This is not apparent with very young children.

  2. Bargaining: This is usually in the form of promises not to tantrum in the future.

  3. Anger: This may be volcanic or simmering, and at times some provocation from parents may be necessary to trigger it fully.

  4. Tearfulness.

  5. Spent/Relaxed.

When initiating the ritual, the young person is to be informed that the task is not to stop a particular behaviour but to enable all family members to escape the oppression of the tantrums and get in touch with each other, and to particularly assist the young person to develop the capacity to make responsible choices in their life. Further, they are told that they should do whatever assists them to vent their feelings fully during the ritual.

Despite growing curiosity on behalf of family members about the exact nature of the ritual, the therapist refuses to disclose details of the physical procedure until all of the instructions and notes, as well as the map of the stages, have been worked through. The therapist then gives instructions for, and demonstrates the ritual hold.

The young person is to sit between the legs of the parent on a kitchen chair, cross their feet at their ankles, and cross and wrap their arms around their own torso. The parent is instructed to cross their feet at their ankles, over the young person’s feet, and then pull the young person’s feet back under the chair. The parent is also to hold the wrists of the young person and pull back with gentle but firm pressure. A pillow or cushion should be inserted between both to counter any harm that could result should the young person throw back their head.

After introducing the structure for the liminal phase, family members should be questioned about doubts and reservations that they may have about the proceeding with the ritual and any that emerge should be satisfactorily addressed by the therapist prior to the end of the interview.

Reincorporation phase 11
In the reincorporation phase, explicit acknowledgement of the family’s arrival at a new status is emphasized. This acknowledgement can be achieved in various ways including by announcing, to various persons who are significant to the family, some of the details of the successful transformation. These details can include information about the difference that “being in touch” has made to the lives of family members.

Family members are encouraged to prepare for this phase in advance by planning “news releases” and/or ceremonies that will render the transformation more public. This encourages those significant persons to discard their “old picture” of the family and to replace it with a “new picture,” thus inviting them to reinforce and in other ways contribute to the consolidation of the various changes.

Family members are also encouraged to prepare for this phase by planning for the introduction of various outwardly observable changes that will signify the instatement of new roles, with a special emphasis on the new place assigned to the young person. This can include plans for physical rearrangements, including the reworking of eating and sleeping arrangements, and details about the space that will be made available for the young person to experiment with new levels of personal responsibility, space that will recognize, respect and test their capacity for dealing responsibly with choice.

Plans must also be made to accommodate the new statuses of the parents. No longer oppressed by the tantrum, they will have choices to face regarding the redirection of their lives and the reorganization of their relationships with others, including with those parents that they were previously apprehensive about “being in touch” with. For parents who are not separated, plans can include ideas for “blowing the dust off” their relationship. The crisis of intimacy that parents have experienced in relation to the ritual, usually prepares them to be influential in establishing a more mutually satisfying and sensitive relationship. For sole parents, the plans can include ideas for the development of more supportive relationships within their immediate community.

Progress is then reviewed by the therapist over several sessions. During this time, s/he provides help in dealing with any contingencies that may arise and gives the support necessary to assist the family to map its progress through the various stages, to assist family members to render their achievements more visible to themselves.

Conclusion
This paper describes an approach to uncontrolled behaviour of children and young adolescents that was developed over some years. I have found that when the uncontrolled behaviour is successfully reframed and the various details attended to, their is invariably a good outcome. The approach in modified form, has also been utilized by other therapists to good effect in contexts not discussed in this paper, for example by staff in residential settings where the young person’s parents have not been available for involvement.

Notes
1. Family Therapist, Leslie Centre, Auckland, New Zealand.
2. This is not to suggest that time-out procedures are not effective with a great number of behaviour problems.
3. This is not to suggest that this tune-out procedure is never indicated and that it cannot be structured to bring about a good outcome (see Menses and Durrant, 1986).
4. The possibility that the young person may be the recipient of physical/ sexual abuse should always be checked out. If it is established that this is the case, appropriate action must immediately be taken before the introduction of the Ritual of Inclusion is even contemplated.
5. For purposes of this discussion I will use the term “tantrums.”
6. I have discussed this elsewhere as the “relative influence” phase of family therapy (White, 1986).
7. Wolin and Bermett (1984) argue that rituals can provide a bonding effect on participants resulting in a very important sense of “family identity.”
8. During this discussion for the sake of convenience, I will refer to the method in this phase as the “ritual.”
9. For example, “In the Smith family, the first ritual took three hours, the second and third took two and one half hours, the fourth and fifth took one and one half hours, the sixth took forty-five minutes, etc.”
10. I urge all therapists who are planning to introduce this method to accompany some families through the ritual process to develop their own awareness of the experience.
11. Also referred to as the aggregation phase.

References

Friedman, R., Dreizen, K., Harris, L., Schoen, P. and Shulman, P. (1978). Parent power: A holding technique in the treatment of omnipotent children. International Journal of Family Counselling, 6, 1. pp. 66-73.

Menses, G. and Durrant, M. (1986). Contextual residential care. Dulwich Centre Review. pp. 3-13.

Turner, V. (1969). The ritual process. New York. Cornell University Press.

Van Gennep, A. (1960). Rites of passage. Chicago. University of Chicago Press.

White, M. (1986). Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles. Family Systems Medicine, 2, 2. pp. 150-160.

White, M. (1986). Negative explanation, restraint and double description: A template for family therapy. Family Process, 25, 2. pp. 169-184.

Wolin, S. and Bennett, L. (1984). Family rituals. Family Process, 23, 3. pp. 401-420.

 


This feature: White, M. (1994). Ritual of Inclusion: An approach to extreme uncontrolled behaviour in children and young adolescents. Journal of Child and Youth Care, 9, 2. pp. 51-63.