• Michael Milgraum

(Article published in the Prince George’s Sentinel, August 5th 2004)

©Copyright Michael Milgraum 2004 . Copying only permitted when authorship attributed to Michael Milgraum and copyright information displayed.


Sam is a thirteen-year-old autistic child, whom I saw for psychotherapy over the course of two years. When Sam began working with me, he had little interest in interacting with me or his peers. In school he would deliberately misbehave, so that he could be sent to time-out, where he could be free of human contact for a period of time. He would engage in short verbal interchanges, when pressed to do so, but only answered what was asked, and clearly derived no pleasure from the interchange.


For a number of years before he came to me, Sam's mode of treatment was what is popularly called "Behavior Modification." This approach, called "Behavioral Therapy" by psychologists, basically involves an analysis of environmental circumstances which either precede or follow behaviors. In this approach, much emphasis is given to the consequences of behavior, because consequences can either serve to reinforce or discourage various behaviors. Behavioral therapy had helped Sam. At the time that his prior therapist started seeing him, he engaged in angry outbursts and tantrums in the classroom when he did not get his way. After behavioral therapy with his prior therapist, Sam was much more compliant with school rules. His progress under a behavioral therapy regimen was not surprising to me, as it has long been one of the major approaches for treatment of autistic children.


For a while, I continued with the behavioral approach, but I began to wonder whether more could be accomplished with Sam than just a minimal level of social interaction and mechanical adherence to rules and expectations. So I tried something different. Rather than trying simply to alter his social behavior by using behavioral principles of reward and punishment, I put my agenda aside for a portion of my sessions with him and explored what Sam wanted to do. I whole-heartedly engaged in any activity he desired, and I played whatever role he designated to me. And I discovered something amazing. Sam was very creative and funny. We started drawing comics together, and after a few months he was dictating a fantasy story to me, which eventually became a forty-page story. Through the course of that therapy, I discovered something even more amazing about Sam-- under the right circumstances, he could be enthusiastic and engaged with another person (me). He would walk into my office, smiling, look me in the eye and say, "Hello Dr. Milgraum, are we going to write our story today?!" So much about that interchange was unautistic-- the eye contact, the enthusiasm and the warmth in his manner. Behavior therapy had gotten him to "behave," but to go beyond that and to help him to relate to others, he needed something more. It is that something more that the rest of this article is about.


The above story demonstrates two principles: One, behavioral therapy can be used to bring about many positive changes in children, and two, paying attention to and developing one’s relationship with a child can cause changes that behavioral therapy by itself cannot. These principles can be observed not only in the therapist's office, but in the home. The behavior therapy language of positive reinforcement (eg., star charts with earned rewards), punishment 2 (eg., time out), consistency in consequences, withdrawal of attention for inappropriate behavior (eg., ignoring tantrums), etc. have filled the consciousness of many parents through many years of exposure to this approach. However, although children will improve their behavior in order to obtain rewards or avoid punishment, they also can be extremely creative in testing limits and making themselves a nuisance, while still not breaking the behavioral expectations that have been laid down for them. So here is the problem that I see with many parents who have oppositional, angry or mischievous children-- Johnny might stop pulling Jane's hair after you put him in time out every time he does so, but that does not stop him from making threatening faces and postures in front of her. And if you tell him that he will get time out as a consequence of this threatening behavior, then he may start making noises she can't stand, or laughing at the way she speaks, or following her around in an annoying manner. Of course, you could tell Johnny that he is not allowed to hurt, threaten or annoy Jane. Unfortunately, though, there are thousands of ways to misbehave and it is impossible to define rules which cover them all. With some children, it becomes clear that they take great delight in demonstrating misbehavior that is not covered by the rules. Parents need a strategy to motivate their children to be cooperative, helpful and considerate, regardless of the technicalities of the behavioral rules that the children are given.


There is another deeper problem with excessive focus on behavioral programs. When a parent comes home and sees his or her child, the parent does not want the child to great him or her only to get a candy reward. The parent wants a greeting from the child because of an emotional connection that exists between them. An emotional connection does not arise out of reward and punishment. It arises out of the parent devoting time to developing his or her relationship with and understanding of the child and the parent creating shared positive experiences with the child.


Filial therapy is an approach which arose out of an awareness of the importance and centrality of the parent-child relationship. In filial therapy, the therapist gives parents guidance in how to "play therapeutically" with their children. Therapeutic play is a process of self-exploration for the child, where the child uses play materials to represent and work through issues or conflicts. Further, the play can become a means of communication between parents and children, allowing the parent greater access to the child's world. As therapeutic play may involve a mode of parentchild interaction which is unfamiliar to the parent and child, a therapist, such as a mental health professional, can provide training, observation and guidance in the play process.


A full description of play therapy is beyond the scope of this article, but a few guiding principles of this process can be listed here. One of the central principles of play therapy is that the child "leads the way." As long as the behavior is safe and not destructive, the child is given the freedom to interact with toys and art materials as he wishes. The child may or may not designate a play role to the observing adult. The parent should only enter into the play if requested to do so by the child, and should stay within the role assigned to the parent. The parent's primary task throughout the play is to be accepting of the child and to demonstrate genuine empathy for the child. Empathy arises out of trying to see things from the child's perspective and making short comments to the child to indicate that the adult has perceived the child's perspective. The adult avoids verbally interpreting the child's behavior or saying what the behavior means to the adult. As the parent follows the child's lead, the child feels affirmed and appreciated, the interaction with the parent becomes less constricted and more positive and the parent-child relationship 3 deepens. It is in this accepting, relaxed context, that the child begins to express the underlying causes of misbehavior and emotional struggles, and the parent obtains very valuable information regarding the child's needs and concerns.


Therapeutic play is not just a way to help children; it also brings an added dimension to the parent's life. During play, parents may connect with a childlike part of themselves, and they can also discover a degree of closeness and harmony with their child that they have rarely experienced previously. The more that parents experience this closeness, the more they are reminded of what is more and less important in life. Daily stresses and worries can melt away in the face of this heart-warming connection, as the parent learns how to appreciate the miracle that is their own child and the many blessings that the parent has so close at hand.



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