Reflective Network Therapy in the Preschool Classroom

by Gilbert Kliman, MD  © 2010

Chapter Titles
Chapter Excerpts


Chapter 1    New Hope for Disturbed and Developmentally Delayed Children
       
Chapter 2    Welcome to the Reflective Network Therapy Classroom

Chapter 3    Reflective Network Therapy: The How-To-Do-It Manual
                   for Therapists, Teachers and Parents

Chapter 7    Help for Children with Pervasive Development Disorders:
                   Reflective Network Therapy and Public School Special Education

EXCERPTS FROM CHAPTERS 1, 2, 3 and 7:

Chapter 1 – New Hope for Disturbed and Developmentally Delayed Children

Loving and learning are precious human functions, often enhanced, impaired or even ruined during early childhood.  Every child whose development or mental health is pervasively or seriously threatened, limited, impaired or devastated has the right to the best resources we can bring to bear.  Because the need is monumental and resources are stretched thin, children who have serious psychiatric problems are often left behind.  Too often, appropriate, even excellent help for such children is sadly limited to managing their most problematic behaviors. Sometimes, small but significant developmental gains may take years of good therapy.

We report here on a therapy which has often produced rapid gains for seriously disturbed or traumatized children. These gains include positive behavioral changes, improved relational skills, and regularly and substantially expanded learning capacity accompanied by significant rises in IQ.  This method often yields its psychometrically measurable results over relatively short periods of time, such as a school year, for most children.  Its results are even better when given with high frequency of sessions, or for longer than a year. We hope others will be further encouraged by the fact that this treatment is less expensive to implement than other early intervention methods.

This book brings parents, teachers and mental health therapists very practical and very hopeful information about a tested in-classroom method for treating young children who have serious psychiatric problems or pervasive developmental disorders. We hope that a careful rendering of our own experience will stimulate new multi-site studies for further independent verification of our own findings. To that end, we offer the support of a replication manual and can provide a video library of in-classroom treatments and scientific presentations.  We are now engaged in getting large numbers of videotaped treatment sessions transcribed and augmented with clinicians’ and teachers’ notes.  We expect the transcribed archives to add another level of objective data for study by independent researchers. …

Reflective Network Therapy makes it possible for a short-handed profession to help more children, and more effectively use fewer human resources than are used in other programs. This is terribly important because we are seeing a world-wide increase in detection and perhaps of real prevalence of early childhood emotional disturbances, (Achenbach 1995, Lavigne 2003).  In the United States, where considerable resources are spent to support early childhood treatment, countless children still go untreated. (San Francisco Chronicle Feb. 4 2005) or receive more limited treatment and less of it than can be provided in classes using the Cornerstone method.

After decades of documented success and proven feasibility, we are sharing this therapeutic method with as wide an audience as possible.  Our nonprofit agency is ready to supplement the information in this book with a variety of additional training materials and expertise to support new Cornerstone groups.  We will, however, do so preferentially, focusing our resources on groups prepared to document at least some initial and outcome data, such as clinical and cognitive condition. …

Reflective Network Therapy is a versatile and practical child treatment method which many communities agencies can learn, adopt, adapt and highly individualize for the very varied special mental health needs of young children.  In this book, we will show communities, agencies, schools, practitioners of mental health and mental health agencies how children can be helped  before they enter first grade, before they have a career of potentially life-long mental and emotional handicaps which inevitably add to the social and financial burden on the community. ...

The Role of Parents in Reflective Network Therapy

 
Parents are integrally involved in their children’s treatments.  From the first moments of evaluation and throughout the classroom work, parents help provide clues to their children’s diagnosis, and often offer valuable suggestions about how to approach them.  Thus parents both use and also enhance the team’s information and influence.  All the children’s education and treatment occurs in a real life space, and is a real life experience within the classroom, not an artificially segregated therapy hour or tutoring lesson. Individualized parent guidance sessions occur weekly, and are given by the teachers and therapist. The parents are part of a reflective network.  Together with the treatment team creates an educational and treatment bridge on which disturbed children travel to later schooling.  The children’s families and teachers carry and support them emotionally and cognitively on their developmental journeys to the wider interpersonal community and, ultimately, to education in regular school classes. 

The second set of parents (growing in number) is those whose children have pervasive developmental disorders, including the autism spectrum and full-blown autistic disorders.  Expressive and receptive language problems are a regular part of pervasive developmental disorders.  So are interpersonal avoidance, oddities of play, stereotypic movements, and hypersensitivy to sound and touch.  In moderate to severe cases the children lack a loving interest in human beings.  They have little empathy, understanding or theory of the mind of others.  Many children with these disorders live and go to school in their communities, but often only with great distress and high economic cost to their families and taxpayers.   For this set of parents, the publication of this book comes at a time when the best known and most widely used behavioral method, Lovaas, is also showing significant benefits (Wisconsin Autism Project 2005).  These benefits include IQ gains similar to those achieved using The Cornerstone Method.  But the Lovaas (Applied Behavioral Analysis or ABA) method has severe relative drawbacks.  The Lovaas method is, in our opinion scientifically respectable and effective.  But it is much more expensive than RNT, requires thousands more hours per year, is less clinically versatile, does not use trained psychotherapists, is deliberately less ambitious in its goals about personality growth among autistic children, and is less clinically documented and studied than what the reader will find here.  Taxpayers and school administrators will be surprised at the large cost-benefit which can come from using the less expensive Cornerstone Method for autistic children, in comparison with the more customary and more expensive Applied Behavioral Analysis method. A separate chapter is dedicated to a discussion of the advantages of Reflective Network Therapy in terms of cost-benefit analyses.

The third set of parents is those who care for foster children.  Those youngsters who are placed in foster care because of neglect or abuse are numerous, and those very youngsters are likely to have a tendency to provoke further rejection.  Their placements with foster families often fail because of child behaviors which are well calculated to provoke or test the possibility of new rejections (bouncing). In a controlled study, we found that about 25% of foster children bounce from foster home to home each year. Bouncing is known to be one of the most psychologically malignant experiences for foster children (Pardeck 1985, Kliman 2006).  Not one of the thirty foster children treated by the Cornerstone method bounced (Schaeffer and Kliman 1990, Kliman 1987, 2006) during the study year. ...

Overcoming Resistance to Learning 

Reflective Network Therapy was originally designed for bereaved preschoolers and was soon discovered to help many young children cognitively as well as emotionally. Countless disturbed preschool children profoundly resist their caregivers’ loving efforts. They stop receiving constructive knowledge from their teachers, parents, and peers.  The following pages have been inspired by the opposite experience, the opening of closed hearts and minds.  The approach I describe has helped most of ten hundred very young children, many of whose hearts and minds were closed, sometimes seeming hopelessly ruined.  An example was three year old Evelyn Urbano whose forty years of life after apparently total recovery from diagnoses of retardation and autism are self-described in this book. ...

Brief Discussion of Distinctive Features of the Method and Underlying Science for Further Investigation

We hypothesize that Reflective Network Therapy goes far beyond interpretations and insight for the child patients.  It uses classroom educational structure and social, networks as a means for emotionally invested and therefore powerful brain exercise, which helps reverse atrophy or underdevelopment of residual internal, neural networks. Perhaps this is the central breakthrough, the core new therapeutic element of the method which allows it to produce more than expected cognitive and clinical results. It is a distinguishing aspect of the Cornerstone method that it is structured to generate multiple, overlapping, interactive social and brain feedback loops which are practiced in such a way as to significantly multiply and optimize the number of opportunities for children to exercise their limbic and cognitive systems and mirror neurons. The children are stimulated to participate in relational interplay by a team of in-classroom helpers who repeatedly introduce observations of the child, with small doses of emotionally and verbally expressed ideas.  They are probably producing mirror neuron stimulation of the child, in the course of adult facial and body language emotional expression, reflecting to child about real life emotionally charged situations as they immediately occur.   In the rich psychosocial life of the Cornerstone classroom, interpersonal behaviors are potentially revelatory to the therapist, and also provide opportunities to stimulate emotionally charged mirror neuron activations.  For the patients, the opportunities abound for brain exercise, not only producing insight in the children but (we believe) producing neurological transformations that account for the IQ and global mental health score gains.

Appropriate to the developmental immaturity, minimal attention spans and low frustration tolerance of most troubled preschoolers, interpersonal events are immediately acknowledged and responded to therapeutically during Cornerstone treatment.  I think that a constant loving, reflective mirroring ignites some neuronal potentials, kindling a desirable set of brain activities. Metaphorically speaking, the flames of learning are fanned by the children’s loves for their teachers, peers and therapist.  The interpersonal passions are created and channeled into constructive paths by the immediate and cumulative effects of a loving team of helper adults.  The adults in turn reflect the child’s experience in many ways directly to the child and amongst themselves, verbally, within the child’s awareness.  This occurs during immediate briefings and debriefings, and within the social context of peers.  It is so natural an experience that often a child hardly notices that a treatment is going on.

The therapist does not allow a child’s behaviors or any event to be considered meaningless, but guides and enables the entire team to be sensitive to the delicate treasures of information available in every interaction viewed from an acutely observing perspective. These small and repeated exercises occur many hundreds of times a year and their influence on the emotion-regulating limbic and mirror neuron systems are, I believe, at the core of Reflective Network Therapy.  In contrast to occasional pull-out therapies, reflections about real-life emotional events happen immediately, often every day for each child, often many times a day.  In a three hour period during a typical Cornerstone day, hundreds of such mirror neuron and whole brain exercising instants usually occur.   The exercises are very specific to the needs of many of the children, especially those who are autistic or numbed for other reasons such as severe traumas, or close-minded because of extreme anxiety and thick crusts of oppositionalism.

The psychotherapeutic component of the method also takes great advantage of multiplier effects.  A multiplier effect is provided by school educational process, peers and teachers, in several ways.  The presence of social and academic tasks enriches the observational opportunities of a child’s therapist, particularly showing when the child is having conflicts or struggling with inhibitions over using his or her own social and intellectual abilities.  The specific behavioral manifestations of conflict, inhibition or interference by impulsiveness become evident and can be shared with the child and teachers immediately, without waiting for a scheduled office session at which time the child would probably have forgotten the problematic details. The presence of concerned peers provides a system of age-similar emotionally rich multiple mirrors, reflecting less anachronistically on learning and social problems than would another adult’s mirror neuron functions.  Peers often provide solutions, as well, which can be adopted by the struggling learner.  Teachers amplify the observational system of the psychotherapist, so there is information given to him concerning more than the therapist’s 15 to 20 minutes of daily therapy sessions with each child.  The teachers have several hours a day in which they see associations and responses the child makes to discussions and interpretations given by a therapist during the child’s 15-20 minute in-classroom session.  Teachers summarize, and routinely cultivate those communications.  A child’s dream, play or fantasy is often the subject of continuing, spontaneously prolonged, extensive and elaborate classroom art, storytelling, dictation and production of playful dramatic events.  The teachers in turn overhear and are told a great deal about the child’s 15-20 minute therapy session and can incorporate this information into the curriculum as well as being informed as to what they may observe.   Further, each child is on the periphery or actually a presence in part of every other child’s in-classroom therapy.  Each child has an activation of affective and mirror neuron systems, learns from all the other children’s therapies, multiplying their empathic and intellectual processes.  As a result of social multipliers, which occur without demand or deliberate effort, the reactions and constructions of all parties in the classroom increase knowledge, as well as enliven each child’s cognitive, creative and therapeutic processes. 

Such exercises, interactions and richness of therapeutic advantages are almost totally lacking in ordinary one on one treatment of a child.  This therapy is also totally different from behavioral interventions such as Applied Behavioral Analysis, which focuses on the individual child’s behavior without a systematic social component, and makes little effort to exercise social systems. Reflective Network Therapy can use every single conversation, symbolic expression, interpersonal conflict, intrapsychic conflict, artistic or story-telling sublimative product, social play, and learning task as grist for the therapeutic mill, to the extent a child and team can usefully address all those shared experiences.  The method requires no great stretch of a preschooler’s memory or attention span, as being in the classroom gives immediacy to discussion and interpretation of observed problem or progressive behavior, by prompt communication within the classroom network.  Each participant’s affect processing and mirror neuron system is deliberately stimulated to represent the human beings within the classroom, and all the events among them, consciously and semantically.

No other therapy currently takes advantage of these natural and immediate opportunities for changing behavior into mentalization and insight, right within the child's natural environment --a nurturing network deliberately assembled, as a classroom of adults and of peers.…

Comparing Reflective Network Therapy to other Interpersonal Methods

 
So far, it appears that Reflective Network Therapy is the only psychotherapy method which reliably and regularly produces IQ gains as well as mental health gains among its patients.  Child Psychoanalysis is a similarly oriented method, but does not regularly produce IQ gains (Zelman 1999).  Therapeutic preschools without an in-classroom therapist (Furman 1969) have never reported such regularly occurring gains (although we can’t rule out that possibility until a few such schools have become psychometric data collectors, include initial and later IQ testing).    When considering other interpersonal methods, which are particularly appropriate for comparison to Cornerstone, we think often of Mahler’s tripartite therapy (Mahler 1968) which made a parent, child and therapist into a reflective team, though not designating the process as such. Cornerstone incorporates and develops this aspect further.  

Although publication of our methods preceded Stanley Greenspan’s (1992) valuable work by decades, some features and goals of “floortime” are identically applied in Cornerstone, particularly the emphasis on promoting empathy and attunement with an adult.  Similarly, RNT psychotherapy sessions are the same length as later adopted by floortime, fifteen to twenty minutes.  The involvement of parents is also central to both methods.  In Greenspan’s method, educators are not used synergistically in the classroom (as they are in Reflective Network Therapy) but they certainly could be.  Although Greenspan’s publications are not yet referring to our data or reporting on their floortime patients’ IQ gains, we suspect that Greenspan’s work could produce such IQ gains.  Supporting our view that floortime outcomes has some resemblance to Cornerstone outcomes, a recent subgroup of 16 floortime treated autistic patients was followed  for ten years, selected because of their promising early response to floortime.  They did very well academically and socially, despite the ominous diagnosis received years earlier (Wieder and Greenspan, J. Developmental and Learning Disorders 9:2005).  …

Linda Wasowicz produced a series of thoughtful reports on autism in March 2007 which was carried by UPI Consumer Health. In her article, Autism Treatments Vary, she discusses structured applied behavioral analysis, centered TEACCH (Treatment and Education of Autistic and related Communication-handicapped Children) and Floortime. This excerpt shows the need for clinical trials  comparing and verifying outcomes and which will hopefully include the currently lesser known method of Reflective Network Therapy.

All these strategies have at least some scientific backing. However, no clinical trials have compared them, and there are "no definitive data showing a clear correlation between an approach and an outcome," said Floortime creator Dr. Stanley Greenspan… (www.ped.med.com, 2007)

One key difference from Reflective Network Therapy is that Greenspan’s method is characteristically though not necessarily limited to dyads, a one-on-one approach.  Unlike Greenspan’s method,  RNT  always uses the classroom network.  Reflective Network Therapy emphasizes systematic ways of multiple helping participants adding reflections, a social hall of peer and adult mirrors, and multiple attunements. In contrast to the Greenspan Floortime method, RNT systematically adds early childhood classroom education, classroom social processes and makes daily use of child analytic techniques.  For those many children who can discuss or listen to a discussion of their own behavior even in the most limited way, we consistently make intensive use of interpretive psychotherapy in the midst of real-life play and interpersonal interaction within the classroom. We use a full range of dynamic and “defense-focused” interpretations whenever appropriate to the abilities of a child.  Defense-focused interpretations particularly concern a child’s resistances to being taught and loved by the adults and peers.  Sometimes it is possible to get a child to understand he is deeply fearful and defensive about intimacies such as receiving information and learning skills. When this information becomes conscious, such defenses can be significantly mitigated.   

 
The Need for Early Life Treatment of Psychologically Traumatized Children

Foster Children/ Social Service Needs for Child Therapy

Disturbed and traumatized foster children constitute another large population of troubled and increasingly difficult to educate young children.  The foster children among Reflective Network Therapy patients have done remarkably well.  One of the unexpected effects among RNT-treated foster children has been a remarkable reduction of bouncing among foster homes (Kliman 1996, 2006).  Well over half a million children in the U.S. are in foster care during any one year, most of whom are placed before age seven (U.S. Department of Health and Human Services, Children's Bureau, AFCARS REPORT 6:1 June 2001). This figure includes many who are resentful and perplexed, closed off by the effects of adversity, and  who have turned away from loving adults and peers by the time they are in grade school. They become wastefully angry, inattentive, defiant, hopelessly withdrawn, or even hateful. Cycles of family dysfunction add tremendously to these childhood burdens, often leading to family collapse and children being given up to social service systems followed by further disruptions of bouncing from foster home to foster home and from school to school (Kliman, 2006).  Finally, a common result is that many repeatedly rejected foster children firmly refuse love and learning.

 
Genetic factors are being regularly found which contribute to the woes of foster children and other traumatized populations. For example, some children are born with a genetic lack of resilience to trauma, detectible by fine studies of gene proteins (Stein, M 2002). Some have a temperamental tendency to anxiety so strong that they can barely taken in new information or deal with school without being preoccupied with worries.  Others are born with a tendency to be too defiant and oppositional to learn.  Many literally cannot pay attention well, probably because of inborn or environmentally determined attention deficit disorders. Genetic difficulties with concentration are often made worse by traumas, anxiety, and exposure to maternally carried or environmental toxins whose effects are indistinguishable from genetically produced attention deficits.

Greater Impact on Community Response

All of the frequent and increasing assaults on childhood mental health −whether  genetic,  chemical, precipitated by  general or specific trauma, societal or environmental changes and stressors and/or the stresses of family life− make this book about Reflective Network Therapy timely. All these recognized mental health diminishing factors create more recognized needs for bringing effective, community-based treatment to very young children. Responding to such needs, we have already shown that an RNT project can work in a shelter for homeless children (The Golden Gate Shelter of the Salvation Army, San Francisco), in a day care center (The Union Day Care Center, Greenburgh, N.Y.) in a County Special Education Department’s preschool (San Mateo, CA), a public special education kindergarten (D’Avila School, San Francisco) as well as in community mental health agencies (The Ann Martin Center, Piedmont, CA, The Center for Preventive Psychiatry, White Plains NY), in our own non-profit mental health agency, The Children’s Psychological Health Center (CPHC) in San Francisco and unbeknownst to me until rather recently, over a dozen  Community Mental Health Centers in Oklahoma  (F. Morris 2002)  

We have concluded that Reflective Network Therapy is a versatile and practical child treatment method which many communities agencies can learn, adopt, adapt and highly individualize for the very varied special mental health needs of young children.  In this book, we will show communities, agencies, schools, practitioners of mental health and mental health agencies how children can be helped  before they enter first grade, before they have a career of potentially life-long mental and emotional handicaps which inevitably add to the social and financial burden on the community.  

At a governmental level, young children’s needs for special education and early mental health services are so great that they are officially recognized in many parts of the world. The U.S. federal government recognizes that handicapping emotional and mental conditions can arise early in childhood, and often seriously interfere with education. The Individuals for Disability Education Act  (IDEA) makes special funding available in U.S. public schools for children who need in-school treatment services in order to be educated or to stop interfering with the education of other children. In light of such great need, this book is an effort to show how excellent results can be achieved with diagnostically varied young children who can be helped economically using Reflective Network Therapy which combines treatment with early childhood education in varied and highly versatile ways, tailored to the needs of each very different child. ...

 
Chapter 2 – Welcome to the Reflective Network Therapy Classroom

 
The day has already started.  Two public school teachers are running the classroom; one of them, Miriam Thompson, has training in special education. As the classroom’s child therapist, I am working with each child, one after another.  Several parents are present and engaged with staff. They are dropping children off, talking to teachers and me informally about recent child behaviors and family events, and receiving some feedback.  Eight preschoolers whose parents and school have determined that they need a therapeutic program attend this class for several hours, five days a week …

Lonny’s history of enormous reactivity to change had been on my mind so it was not surprising to find him in a rage today.  He was storming mad, both howling and weeping.  As I soon learned from the head teacher’s briefing, Lonny had just kicked Daniel, apparently in retaliation for Daniel having touched some dishes with which Lonny was arranging a “tea party.”

I had begun to realize that Lonny, who had an almost average IQ, suffered from Asperger’s syndrome, a disorder which was then becoming increasingly commonly diagnosed.   It is a mild form of autism, usually associated with normal intelligence but characterized by limited understanding of the mind and feelings of others.  Lonny seemed intellectually bright at occasional moments, and loved to talk about mechanical things, regardless of how others responded to his monologues. I thought we might be able to harness his particular set of interests to his benefit and I looked for opportunities to do this. Lonny seemed sweet, despite his history of violent outbursts.  On this occasion, although it might seem curious, I was not sorry to see him angry at another child’s actions. I considered this an opening to be seized, because his response was at least in part to a living human being, rather than to a piece of new clothing or a change of physical situation.  Further, his extremely aggressive behavior had immediacy; it was right in front of his and my eyes and was being discussed in his presence. He might not be able to avoid realizing that his injured peer, his teachers, and I were all perceiving and thinking of his behavior as unreasonable, unacceptable and self-defeating. …

That day, Lonny had the first session with me among the eight children, each of whom had daily twenty-minute in-classroom sessions with me.  As his session began, Lonny was in disciplinary trouble because of kicking Daniel.  We began with Miriam, his head teacher, briefing me about the trouble, while Lonny listened and howled, with some attention to the rhythm of the dialogue Miriam and I were having.  It seemed he was part of the communication, with his howls punctuating our conversation like a chorus.  Lonny, Miriam told me, was being given a time-out for having kicked Daniel.  Lonny had chosen to take his time out by taking shelter under a small, round classroom table.   Miriam wasn’t sure why Lonny was so upset with Daniel, but she thought it had something to do with Lonny not wanting the things he was working with touched.  I listened and thought and observed Lonny while sitting near him on a tiny chair designed for small children, but quickly moved onto the floor beside the table under which he crouched, gauging and adjusting my proximity to his changing receptivity.

I also had some associations of my own.  Miriam somehow reminded me with her momentarily stern and unmusical tone that Lonny’s mother had pointed out during a parent guidance session how Lonny liked a soothing musical voice.  He liked to be sung to!  Miriam was not singing.  She was rightly occupied with maintaining order in the classroom, protecting Daniel, while promoting circumstances in which Lonny would have a turn to work with me. Although my own children have told me they would gladly pay me not to sing, I decided to talk to Lonny by singing to him, using the name he liked to call himself, "Jack".

From my position on the floor near Lonny’s refuge, I began reflecting the immediate events which preceded his time out and self-imposed physical isolation under the table,  using a simple, repetitive tune and sing-song rhythm: “Jack was having tea. Jack was serving tea…Somebody named Daniel−”  At the mention of the name of the boy who had offended Jack, his howling and screeching momentarily increased with a vengeance.  I continued singing:

            Daniel took Jack’s tea and he

            shouldn’t have taken Jack’s tea…

            And Daniel took the tea from Jack

            without Jack’s permission−

Jack was having a big tea party.

            For everybody.

            And Daniel spoiled it.

At this point, Jack is seen in the video briefly wiping tears from his eyes and, a moment later he inches closer to me, wrapping one arm around the table leg closest to my position and leaning towards me.  Lonny seemed enchanted. I sang on...

Chapter 3 – Reflective Network Therapy: The How-To-Do-It Manual
                   for Therapists, Teachers and Parents

 
Settings

Reflective Network Therapy works well as an enrichment added to an ongoing special education service.  It can also be a separate classroom service as has been done in San Mateo and San Francisco Unified School District.  It can work in a part-day or full-day preschool, daycare or serve as its own full-time preschool. Inclusion of a service for RNT children into a larger public school special education class, Head Start, daycare center or similar agency is valuable in achieving a full mainstreaming of the patients the next year.  Inclusion in a larger public school is a means for encouraging social growth of RNT patients within the larger community.  It helps de-stigmatize the psychiatric problems of young patients. …

Reflective Network Therapy is an inclusive method, deliberately keeping disturbed children within their classroom special education groups rather than pulling them out of class for behavioral modification or psychotherapy.  It does not segregate or isolate children socially from inclusion within a group by having an adult aide constantly at a child’s side. RNT treatment and education gives a child a gradual transitional preparation for entry and inclusion into the larger, real world.  It cushions children, protecting and limiting their actions and serving as a stimulating but protective half-way house en route to the more demanding larger community.  It is a holding environment, in Winnicott’s (1965) sense, which gives children opportunities for soothing, impulse-containing and expression-supporting relationships, thus not only allowing growth but also correcting for developmental difficulties (Alpert, 1941, 1953).  Children are contained by the thoughtful, understanding presence of teachers and a therapist who understand each child’s developmental status, needs and individual impulse control limitations, and who encourage the evolution of his or her expressive skills. …

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Standards and Structure

There is a range between certain ideal and minimum standards for practicing Reflective Network Therapy.  Deliberatey being repetitive, we will emphasize throughout the manual that some guidelines and aspects are considered essential, such as:

1. There must be at least three and no more than twelve children in a group, Children are between ages two and seven.
2. One child therapist is assigned to each classroom of up to twelve children.
3. Each psychotherapy session occurs only in the classroom.
4. If more than three children are present, two preschool educators are needed, to conduct educational activities while one child is treated at a time within the classroom
5. Educational activities can occur daily for full classroom days which occur five days a week. They must occur at least two hours a day, at least two or three days a week, totaling at least six hours a week if there are eight patients.
6. In-classroom psychotherapy sessions must occur with each child at least two and preferably five separate days a week.
7. Each session should be preceded and followed by a “briefing” or “debriefing”
8. Methodical insistence is required on a child’s individual therapy taking place not only in the classroom but in the presence of other children and teachers rather than being in any way hidden from them.
9. Weekly parent sessions must occur with a staff member, sharing what has happened in class and home.
10. Weekly staff conferences are needed, sharing what has been going on with the treatment
11. Parental permission should be secured so videotaping can be regularly used to assist at staff conferences, and for objective follow ups.

 
The method is based on a network of intersubjective influences, not just a therapist’s, teacher’s or aide’s influence.   In order to be sure that RNT service is well set up, all the component pieces must be present and interconnected. If a certain piece of a network influence is lacking, a network’s communication processes might go down.  We aren’t sure why this is so, but it may be analogous to an internet server’s disconnect causing a widespread e-mail outage or a broken wire causing lights to go out in a larger but highly connected electrical grid.  …

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Essential In-Classroom Procedures Include:

1. In-Classroom Briefing
2. In-Classroom psychotherapy sessions for each child, multiple times a week.
3. In-Classroom Debriefing
4. In-Classroom educational activities
5. Team Conferences weekly

 
Briefings are structured times of communication among two adults (teacher and therapist) and the child. These communications involve the teacher and child jointly narrating a summary to the child’s therapist about the child’s day so far. The summary is given in the classroom immediately before a child’s in-classroom psychotherapy session begins. This briefing serves several functions for the particular child who is about to have a psychotherapy session.  The briefing gives the child practice in experiencing being thought about by two important adults (teacher and therapist) at the same time. He processes the emotional expressions as well as words of the two adults who are collaborating about him.  He develops a theory of multiple minds.  He has a chance to practice learning how two to a dozen people can have caring and detailed knowledge of his behavior and shared but individually varied theories about his mind.  During the next fifteen or twenty minutes, his psychotherapy session is necessarily influenced by his knowledge that he is being thought about and his expectation that this experience will occur every time he is in a Reflective Network Therapy classroom.

Pre-Session Briefing

 
Briefings are structured times of communication among two adults (teacher and therapist) and the child. These communications involve the teacher and child jointly narrating a summary to the child’s therapist about the child’s day so far. The summary is given in the classroom immediately before a child’s in-classroom psychotherapy session begins. This briefing serves several functions for the particular child who is about to have a psychotherapy session.  The briefing gives the child practice in experiencing being thought about by two important adults (teacher and therapist) at the same time. He processes the emotional expressions as well as words of the two adults who are collaborating about him.  He develops a theory of multiple minds.  He has a chance to practice learning how two to a dozen people can have caring and detailed knowledge of his behavior and shared but individually varied theories about his mind.  During the next fifteen or twenty minutes, his psychotherapy session is necessarily influenced by his knowledge that he is being thought about and his expectation that this experience will occur every time he is in the RNT classroom.

 
The Pre-Session Briefing is followed by Play Therapy. 

Fifteen to twenty minutes of in-classroom psychotherapy is provided to each child for as many days a week as the class meets. All of the play therapy sessions take place in the classroom so that the real-life behavioral confrontations and insights developed with the child are shared and verbalized immediately with him or her and the teachers, in the presence of other children and some parents. It is critical that this is done regularly and right on the spot, before meaning is lost to the child’s immature memory and limited attention span or buried by such defenses as avoidance, denial, repression, isolation, dissociation or projection.
 

The Individual Psychotherapy Session must be followed by a Debriefing.

The debriefing is an interpersonal event lasting a few minutes. It contains a structured effort to communicate and provides opportunities to view, mirror and identify with others’ feelings and behavior.  The child and therapist endeavor together to speak to the teacher about the nature of their session to the teacher. When the child cannot or will not verbally narrate his or her own experience of the session, the therapist fills in the teacher, while in the child’s presence.  There is a deliberate recursiveness to this process, as each player has important input into the others’ communications and other interactions and receives input about those which didn’t directly include him or her.  Other children in the classroom may be part of and listen to the index patient’s psychotherapy and may hear and participate in the debriefing.

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In-class psychotherapy sessions should take place two or three to five times a week; the duration of each session is 15-20 minutes.  These sessions usually following a fixed schedule in which children’s names are posted in sequence on the classroom chalkboard.  Many children quickly learn to read all the names.  Each becomes in turn an index patient within the real life space of the classroom.  On any given classroom day, every child usually receives a session.  The total number of sessions has an orderly correlation with outcome, especially of IQ gains, so we encourage more rather than fewer sessions. Reports by Marianne Lester, M.A. (1997) of successful twice a week treatment have been confirmed by work of Tish Teaford, MFT. (Hope 1999)  We have found Cornerstone treatment usually needs at least a school year before there are lasting good clinical and cognitive results. The variation of clinical response velocity is immense, however.  We have documented selectively mute children, who never spoke in another school, becoming in-school speakers in a single day! …

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Control and Participation

The index child is the child who is therapist’s primary focus during a therapy session. Other children will have their turns.  They should be allowed to help the current index patient, to the extent they do not interfere with that child’s play and allow that child to have his way in temporarily controlling and the expressive process.  Teachers and therapists unhesitatingly remove a disruptive child from the vicinity of the index child’s play session.  In practice, most children are initially jealous of the classroom therapy time their peers receive but usually become collaborative in a few days or weeks.  Soon they value the sessions so much that most Cornerstone children become altruistic, helping each other to have sessions, and supporting each other’s efforts to talk during the classroom sessions.  Videos show the RNT-treated children often help each other work at their highest abilities, and nurture each other, each respecting the rhythms of the others and identifying with the helpfulness of the classroom adults.  Their empathy and altruism is readily commented on by the adults.  Such commentary provides a behavioral reward for intrapsychic and interpersonal growth.

The network effect is enhanced on a peer level by allowing children to hear one another’s sessions, and to help the index patient play in whatever fashion the index child chooses. As jealous or mean interference by peers tends to be remarkably infrequent once children settle into a new group and join Reflective Network Therapy's culture of kindness, outsiders viewing our videos are often surprised by the altruism the children show. Because children learn to be reciprocally considerate of each other, collaborative and enriching behavior becomes self-sustaining. …

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Weekly Parent Guidance Sessions

Weekly parent guidance sessions, 45 to 60 minutes in duration, are conducted mainly by the head teacher.  Once a month, the parent guidance session with the teacher is replaced by an hour with the classroom therapist. Sessions usually occur in a private office within the school, but have often been effectively carried out in a corner of the classroom during classroom activities. Weekly parent guidance sessions start soon after the child’s acceptance into the classroom, and the parent must be prepared to invest an hour a week with the teacher.  Routine home or telephone visits for some home-bound parents can replace a session in an office.  Resistance to attending parent guidance is often not only the parent’s problem but a product of teacher’s unfamiliarity with relating so intimately to an adult rather than a child.  Thus, a therapist can useful supervise the parent guidance, during staff meetings. …

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The Role of Parents in Reflective Netowrk Therapy Classroom

Parents are valued team members, participants who are absolutely essential to the network process that heals children in the RNT classroom. In addition, parents are fortified themselves in the process, bolstered to continue their challenging parenting roles even more fully. Parents should always feel welcome in the classroom.

Parents are encouraged to stay for many days at the beginning of a child’s experience in the RNT classroom. Later, they may just drop the child off.  The daily parent-teacher briefing which occurs when a parent drops off a child often takes just a minute but is an important structured opportunity for the parent and child to be impacted by witnessing reflective network therapy time and again.  In addition, the content of those parent and teacher briefings are often used to accelerate the child’s recovery. For instance, Oscar’s mother (in the case described above) provided critical information about specific family violence which immediately enhanced the therapist’s ability to interpret the child’s social difficulties and violent, frenetic behavior. During parent guidance sessions as well as in class, this contributed much information about Oscar’s anxieties concerning body integrity in the face of family violence.  Over time, she was also rewarded by the child’s growing social abilities and ability to express tenderness.  …

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Parent Guidance Conferences

Once a child has been evaluated, there is an ongoing parent guidance process in which both the teacher and therapist have roles.  The staff finds it easier and easier, with experience, to be respectful of each parent’s burdens and knowledge concerning their child.  Parent-blaming and adultophobic attitudes, which were common at one time in psychotherapeutic and educational professions, are lost with training and experience.  Staff becomes increasingly sensitive to parents’ attitudes toward living with a difficult and changing child, fluctuating mutual dependency needs, and often sudden shifts in aggressivity and affection.  Staff develops a heightened awareness of the parent’s ability to make critical contributions to the child’s recovery.

The staff-parent meetings require sympathetic listening, sharing observations, helping parents to carry insights gained in the classroom into the home environment, supporting parental capacities and responsibilities.  Since this method depends on a network influence, the teacher must model communication skills during these meetings, conveying to parents much about how she thinks and feels about the child. Helping parents accept their child’s perceptiveness about home adversities and changes is routine and helping the child mentalize those experiences in child appropriate doses and with parental support is essential. Conversely the teacher can convey information about the child’s intersubjective life in the classroom, making a bridge between home and school, verbalizing and placing the child’s functions in a developmental framework that a parent would usually find more difficult than a teacher to conceptualize.

The therapeutic nursery teacher's weekly parent conferences have four main functions:

1. Receiving information from the parent about current family events,
2. Sharing information with the parent about the child’s classroom experience
3. Giving educationally oriented developmental guidance, and
4. Giving support to the parents or parent surrogates.

RNT parents receive the deep emotional sustenance required to set up a constructive nurturing cycle of reciprocal love and caring with their children.    The failure of a child’s reciprocity is depressing to and depletes many parents. Reflective Network Therapy assumes that each parent needs and deserves such support. Parents need emotional nourishment in order to care for very troubled children. Many children referred to Reflective Network Therapy do not readily reciprocally nurture their parents, in that they do not return their parents’ love in wholesome ways.  In such families, each parent has the burden of living with a child whose emotional life is difficult to support, and whose relationships are layered with resistances and problematic neurobiological complexities.  The child’s special assets and deficits, as well as their communications, are often puzzling and quite different from what other families experience.  Most parents have been frustrated, disappointed and discouraged –and sometimes immobilized-- in major aspects of their relationship with their children, no matter how much they love them.  Parent guidance sessions go a long way to mitigate the resulting pain and confusion.  Strengthening the child’s primary support system in turn strengthens the possibilities for the child’s home environment becoming as nurturing as possible throughout treatment.

Parent conferences are conducted on an individual basis. The teacher sees the parents (mother and father, if possible) or primary caregivers weekly; the therapist sees them once a month. Current information, current events, and earlier events of importance are reported on this weekly basis to the teacher and are transmitted to the therapist for use in his or her daily work with the child and in the therapist’s monthly sessions with the parents. The child knows that Mommy or Daddy, or whoever sees the teacher, sees the teacher regularly and that the teacher and therapist share information directly with the parents or caregivers. The teacher helps the parents understand the needs of the child, especially how to cope with the child's developmental process. Some parents must be helped to know the difference between what constitutes normal development and what is peculiar to their child. The parent is empowered to cope with the child's difficulties as well as changes on a day-to-day basis and acknowledged for doing so. …

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The Reflective Network Therapy Teacher: Clarification of Roles and Responsibilities

The roles of the teacher in the Reflective Network therapy classroom are many. The teacher has roles as a reality oriented educator, as communicator between the patient and the therapist, as a stimulator, receptor and observer of communications and behavior, and as an observer of responses to interpretations when those responses occur after the therapist has left the classroom.

There is a synergistic division of roles in RNT. Therapists are not educators in the formal sense. Therapists use a broad repertoire of psychotherapy techniques individualized to a particular child. Cognitive restructuring, dynamic interpretations, and transferential interpretations are feasible within RNT (Kliman, 1970) It is essential to the method that the respective roles of the teacher and the therapist be made clear for the children. The children learn the therapist is there to talk about, interact with, interpret and clarify the child's behavior and thoughts. The teacher is there for educational tasks, in the broadest sense, as well as for discipline management.  One child showed his clear understanding of teacher and therapists’ different roles as he finished a block building and said to the teacher, "It's my turn to be with Dr. K." He pulled a rocking chair over to Dr. Kliman, who was sitting nearby and said to him, "let's work," and then began to talk about his dream of the previous night.” (Kliman and Ronald, 1970)

The teacher is responsible for developing and implementing the curriculum and educational plan appropriate to each child’s abilities and for supporting the expectation of progress in socialization.  The teacher advances curriculum implementation by constantly adjusting to children’s responses and performance.  For example, most children are expected to and do sit in circles and “dress the weather man” with weather-appropriate clothing each morning. If they can’t do it, the children are still given the expectation of accomplishing this group activity.

The teacher prepares the children to adapt to transitions without emotional upset. For example, children are helped to learn about the calendar and time, and to anticipate the rhythms of weekends, vacations, and each other’s absences.  The teacher helps build ego strengths related to handling transitions involving gratification delay.  For example, she may help a child learn how to wait or how to share. The therapist will not teach but will interpret a difficulty in sharing or waiting, the more so as the child becomes increasingly aware of the functions of sharing and waiting.

The teacher models good reality testing and good communication about realities. There is much value in teachers talking to children in small groups the about the unavoidable upsets that inevitably occur, such as a teacher’s illness, a pet’s death, a birth in a family, or the hospitalization of a parent or grandparent. Such discussion psychologically immunizes children against being overwhelmed in the event of any future, more destabilizing events (Kliman, 1968).

The educational program additionally consists of helping the child to explore the real world around him, with all the ramifications of learning to develop logic, order and problem solving ability as related to his world. (Kliman & Ronald, 1970) 

The therapeutic teacher is responsible for providing a program designed to promote the social, emotional, physical and cognitive development of each child. In this setting the therapeutic teacher also assumes the traditional educator’s role of providing a socializing influence by managing children’s disruptive or aggressive behavior, freeing the therapist to do his or her interpretive work without the complication of such responsibilities.  The teacher’s opportunity to work daily in such tandem with the therapist in a preschool setting is a core part of this method. …

[For more Excerpts from Chapter 3, please see the Manual section within the Method category on this site.]

Chapter 7    Help for Children with Pervasive Development Disorders:
                   Reflective Network Therapy and Public School Special Education

Full Discussion of Multi-Site Study of Reflective Network Therapy Results: Twice-Tested Children

Features of Reflective Network Therapy Used in This Most Recent Study:

No aspect of Reflective Network Therapy was left out of the treatment given to the intervention group.  In the control group, none of the Cornerstone procedures were used.   In the comparison group, all features except interpretation were used.

Reflective Network Therapy is a "real life-space" method (Redl 1959) of applied child psychoanalysis. Previous publications include case detail showing that the in-classroom situation permits an individualized, insight-producing method, based on transferences and using many highly individualized interpretive maneuvers tailored to the particular child (Kliman, 1968, 1975, 1997; Lopez & Kliman, 1980, Lopez, 1996 and 1980, Stedman, 1997, Zelman 1987, 1995, Stewart 1996). Each child in a group of six or eight patients is treated highly individually by the psychotherapist right in the classroom, and only in the classroom. This happens in the midst of classroom activities and among the child’s therapeutic education peers and teachers. As was the case when we practiced the method when collaborating in the California public special education setting, usually there are two teachers, one therapist and six or eight children in a class, which meets at least three hours daily. Some teams have met less often and for shorter times, some as little as twice a week for three hour classroom periods totaling six hours.  Treatment sessions usually focus on themes suggested by the child’s here-and-now issues, expressions and behaviors: spontaneous play content, symptoms, drawings, dreams, separation distress, social anxiety, difficulty with cooperation, lack of emotional receptivity, lapses of attention, conflicts over peer relationships, failure to enjoy play achievements, and emotional problems in learning or conforming to classroom rules. Transferences readily develop, and useful interpretations can be made.

Primary caregivers also become part of the in-classroom synergy. The method includes a procedure for sharing input daily when the children are delivered to class or picked up after class (briefings and debriefings. Sometimes a parent and the teachers report that the child’s symptoms are more evident in the treatment situation than at home, which is a great advantage for helping the child work through his problems during his daily short therapy sessions (Kliman 1970, Lopez and Kliman 1075). Interactions with peers (or lack of them) are often a subject of interpretation, as are the family’s current and historical issues. Resistance to the opportunities and gratifications of learning and socializing are especially likely to be an analytic focus. Parents are regularly included as part of the treatment; they receive weekly guidance and are encouraged to be involved in classroom educational work whenever possible.

Teachers have special educational and relational but not interpretive tasks. They confer with the classroom therapist weekly, and keep charge of the classroom activities, with the exception of the content of each child’s daily 15-20 minute therapy session. Most of the remaining time, each child is engaged in special education activities of a highly socializing and cognitively oriented nature. Often these activities continue themes which are developed in therapy sessions. In-classroom briefings among the adults, in the child’s presence and with his help, are an essential feature of the method. Before each therapy session, teachers give daily verbalized briefings to the therapist about each child’s recent events, behavior and concerns. This is done each treatment day, in a classroom triad composed of teacher, therapist and child; this team grouping is expanded when a parent is present to be included. The adults strongly encourage the child to participate in this process. Each child is thus intimately discussed with his own help, in a supportive, nonjudgmental but persistently mentalizing way. Practice of this skill is considered an important feature for all parties to the task as transforming behavior and feelings into words is a critical objective for mental and cognitive growth. The process deliberately includes an enticement to mentalizing (Fonagy 2002) rather than behaving. This enticement is partly generated through the constructive use of the child’s yearnings to be close with and identify with the therapist and be loved by the teachers and peers. 

In the most intensive form of Reflective Network Therapy, each child has four or five therapy sessions each week. Each session generally lasts about 15-20 minutes but occasionally can be varied to be 30 minutes. The longer sessions are usually given after a session has missed therapy sessions due to the child’s or the therapist’s absence. The session ends with the therapist and child together briefing the teacher about what they have done during the session. Other children overhear and often participate, sometimes making remarks or contributing playfully in each others’ sessions. The participation of peers is conditionally allowed. Other children must be willing to let the “index patient” be the one in charge of what is done during his own therapy time. Generally, RNT-treated children are remarkable for how they jealously prize and eagerly await their turns. As empathy develops, they try to share more and allow each other the same privileges and enjoyments of treatment as they prize for themselves.

As a toddler’s parents often do, the RNT analyst attracts a child into a dialogue by taking an interest in what the child is already doing. In cases of Pervasive Developmental Disorder, mentalizing is crucial to everything which proceeds thereafter. From the child’s point of view, interpersonal investment has to precede the mentalizing.  Interpersonal investment is a predecessor of attachment to ideas.  Mutuality of interest in the child’s ideas is a predecessor for the child’s attachment to his own mentation.

In Reflective Network Therapy, we literally model an investment in mental life for the child and parent. The teacher-therapist team is a model of an adult family-like team that attaches to a particular child’s mental life very individually and very specifically. We channel children’s activities and impulses in favor of sublimations of raw action. We use disciplinary methods such as delay, discussion, limit setting, and consequences such as time outs and withholding privileges. We use consequences which also afford practice in toleration of frustration, for example by requiring a child to wait a period of time before using certain equipment that the child has previously misused. Redirection of energy or inappropriate behaviors is practiced in many ways, including suggesting alternative activities or offering acceptable choices such as touching of a doll’s body rather than sexual exploration of a peer.

We endeavor, in each case, to develop a highly communicative therapeutic family to which the child becomes attached. The analyst is a crucial and daily member and part of that family. The family soon becomes authentic in terms of shared regard as well as artificial or therapeutic. The transactions on a daily basis are real and not identical with transference in regular child analysis. The latter is largely a product of the child analyst being used as a blank screen for projection of the child’s internal world. In Cornerstone, the children are often sufficiently primitive and the treatment so real-life based that the therapist may be witnessing and commenting while a teacher is changing a child’s diaper or when she is moderating a squabble between peers. Furthermore, even the most developmentally advanced children must be given cognitive and socializing education within the classroom, and the RNT therapist is often at the child’s side and commenting analytically on much of the child’s behavior during such educational process. This reality base creates a different kind of transference than it would were it merely based on fantasy and redirection of emotional history. Rather than the rarity of a child giving his own verbal account of educational and social events, the child’s commonplace actual educational and social events are the subject.  They are the focus of immediate shared perception and discussion with the analyst and the rest of the adult network in the classroom. This aspect of shared real time experience tends to increase real love for the analyst.  It also reduces transference fantasy somewhat and increases reality as a factor in transference. Having the analyst present at the child’s side when actual problems are encountered in the social and educational process certainly increases the immediacy of the value of the analyst to the child.

Fully using and understanding the RNT method requires a theoretical leap from the dyadic realm to the realm of both intrapsychic self-psychology and network psychology at the same time. In the psychological process of the method, the patient’s brain and self-representation (often and daily) are the central focus of a complex therapeutic community. The child patient sees himself reflected in the verbalized and affective realm of peers and adults. At the session’s beginning, the child hears and sees himself discussed with much affect, interest and intelligence by the teacher as she briefs the analyst. During this overture ─the beginning of a complexly orchestrated symphony of interpersonal expressions and receptions─ the child is asked and urged by both adults to participate in the melody and words of the briefing. During this procedure the child receives and, with practice, internally assimilates some of verbalized representation of himself as perceived by the teacher and as perceived by the analyst who comments on the perceptions expressed by the teacher.

The process is more than psychological. Many portions of the brain are activated and exercised by this procedure, simultaneously investing mental representations with resonating versions of the external emotional environment. It is likely that at least the hippocampus as well as frontal lobes, as well as cerebellar, visual and auditory and inter-hemispheric communication areas are repeatedly interacting, stimulated, and their pathways potentiated during the Reflective Network Therapy briefings. The child basks in the warm and gratifying glow of nonjudgemental adult interest and verbalization concerning his person. He is often relieved and eager to learn about features of his behavior which are subjects of hostile or avoided communication elsewhere in his life.

Gratified, frustrated and educated simultaneously during the pre-session briefing, the child goes on to valued play with the analyst as the analyst’s index patient. During this fifteen or twenty minute session, the analyst and child chat about the child's activities. Only that index patient can take the valued center stage. Other children in the classroom are allowed to participate only if they subordinate their play to the themes and activities to the narcissistic interests of the index child. For the sake of having the same privilege, most patients will surrender their own interests temporarily to those of the index child, thus learning altruism and contributing to the mirrored complexity of the mental life of the index patient.

Finally at the end of a quarter hour or so of gratifying and cognitively active primacy, the index patient experiences a remarkable and fascinating redundancy of communication. Once more the child becomes the subject of at least a three-person communication. This time the triadic talk concerns events that have been closely subjected to verbalization by the dyadic team of child and analyst, who now have the task of conveying to the teacher just what they have been doing. The analyst usually takes the lead and summarizes for the teacher what he and the child have been talking about and doing, enlisting the child in the process, drawing upon the child's love for the teacher and his desire for her attention. Often, for the first times in his life, the child hears himself described intimately and uncritically to an adult dyad. This encourages the child to use neutral thoughts to contemplate his own self in terms of how he is perceived by others in a context which enables him to use the internalized reflections to become more adaptive as well as more self aware.

Study of Reflective Network Therapy in San Mateo Public Special Education 

 
Characteristics:

There were ten San Mateo, California public special education children, six San Mateo public special education controls and three San Francisco comparison treatment cases.  In keeping with the demand for therapeutic services for PDD within special education classes, all of the treated Cornerstone children in the new California data were boys who had IEP’s (Individual Educational Plans) and school psychologist examinations. They met DSM IV criteria for Pervasive Developmental Disorder. Most had mild to moderate autistic features. Some were under consideration for other disorders as well, including Oppositional-Defiant Disorder, Posttraumatic Stress Disorder and severe attention-deficit disorder. None were given medication although one started out with several medications already prescribed and gradually withdrawn with our advice. 

The average full-scale WPPSI IQ on entry was approximately 70 and the range was from 45 to 108. All 10 public school children had Individual Educational Plans (IEPS), complying with federal legislation. Six controls had PDD and were untreated except for their special education, attending their daily special education class in a different region of the same community school system as our public school Cornerstone class. They were geographically close, of comparable ethnic and racial characteristics, and with similar SES. All but two children were Caucasian boys. Expressive and receptive language disorders were present in all of the children. One boy with Asperger’s Syndrome whom we treated had marked avoidance, rages, psychotic states, idiosyncratic language, obsessive interest in transport vehicles, lacked a theory of the mind and interests of others. He had pragmatic pathology in his voiced speech and language. He started with a normal IQ of 98.

At the start of treatment, this group of 19 studied children ranged in age from 3 years to 6.5 years with an average age of five years. At the end of treatment, the children ranged in age from 4 years to 7.5 years with an average age of 6 years. Based on the three hierarchical factors of amount of education, type of job and salary, each family received an economic classification: 2-3 out of 3 factors scored as upper class, 1-2 out of 3 factors scored as middle class, and 0-1 out of 3 factors scored as working class. For the total group of children, nine were from working class families, five from middle class families and five from upper class families. Eight of the children had both parents in the home during the treatment year. Another eight children had one parent living with an extended family member. One child lived with his grandparents and saw his mother on the weekends. Three children were in foster care and had no contact with their birth family. They were cognizant of the birth parents’ existence and had lived with at least one of their birth parents for at least 1 year. Ten children were Caucasian, six Hispanic. Two were African American. One was Middle Eastern.

‘External trauma’ was quantified by the presence of the following in each of the child’s school or social service records:  physical abuse (including maternal substance abuse during pregnancy), sexual abuse, neglect, general abuse/type unknown, or none reported. Emotional abuse is included in the general abuse/type unknown subcategory. Homelessness as a type of trauma to a whole family is included in the neglect subcategory. Eleven of the children had no reported external trauma in their lives. Five children had both neglect and physical abuse in their histories while two of the children were in the general/type unknown subcategory. One child had experienced physical abuse, supposedly without neglect.

Link to Chart in Research and Results Section: Multi-Site Summary of Reflective Network Therapy Results: Twice Tested Children

Chronology of Treatment, Data Collection and Testing:

Ten consecutive IQ testable and then retested children with PDD were treated  with Reflective Network Therapy within their California public school special education classes, in San Mateo during the years 1995 through 1999. Two additional cases are offered, a San Francisco case which is the first to be retested, and a twelfth new child, the first re-tested Oklahoma case. The latter is not unselected. He was remembered because of the Oklahoma therapist’s recall of an IQ outcome. He had several IQ testings, the first when treatment began in 1976 and the last in 2001.

In this study (Diaz Hope 1999) a blinded, outside rater scored all of the San Mateo children according to the CGAS, which is a scale of behavioral, emotional and social functioning. Contemporary Children’s Global Assessment Scale (CGAS) data was not available from the New York or Oklahoma study. In looking at the CGAS change scores of the California children with moderate and major psychiatric diagnoses across all groups, there is a significant difference between the lumped Cornerstone groups and the lumped Control/Comparison group. There are not detectable CGAS differences within quantities and frequencies of Cornerstone treatments. The CGAS measures of children with the most problematic behaviors improved significantly in a special education classroom with Cornerstone treatment but not in a control special education classroom in the same school system without Cornerstone treatment. The CGAS change score mean gains were the following:  Cornerstone 15, Supportive-Expressive Comparison Group 3.0 and the Control Special Education Group 0.5   Thus, it would appear that the Cornerstone children improved not only cognitively (IQ rise measured by WPPSI-R.). They also improved significantly in social, emotional and behavioral dimensions (CGAS) as well and far more robustly than the comparison and control groups (Hope, 1999).  The most significant of the two measures, in regard to the influence of number of sessions, was I.Q.  I.Q. rose directly in proportion to the number of sessions.  The less psychometrically precise factor of CGAS did not discriminate well except between treated and control populations.

Other Aspects of the IQ Data:

Initially, the Cornerstone treated San Mateo children had IQs between 45 and 108. Reflective Network Therapy ("Cornerstone" treatment") produced Full Scale IQ gains significant at the p < .01 level. Cornerstone was more cognitively effective (Full Scale IQ rose with p =. 005) and social behaviorally effective (CGAS rose with p =. 01) for children who had more than one major psychiatric diagnosis. Additionally, the most intensive Cornerstone treatment (four times a week) produced almost twice the amount of cognitive improvement as less intensive (once or twice a week) Cornerstone treatment. The average intensive therapy result in the San Mateo public school four times a week Cornerstone was a Full Scale IQ gain of 28.75 points, while the less intensive (once or twice weekly) San Mateo public school Cornerstone treatment produced an average gain of 14.7 points (Diaz Hope, 1999, p. 91). The CGAS distinction between Cornerstone and control/comparison subjects was significant at P = .01.  CGAS rose with Cornerstone treatment and not with control or comparison status.  But we could not distinguish the CGAS effects of two versus four Cornerstone sessions a week.

Both IQ rise and CGAS gains both occurred without exception among the new subset of ten consecutive treated Cornerstone children in California.  This was far exceeded by the impressive IQ gain (80 points) in the Oklahoma child, who was however, a selectively recalled child. The lack of exception to the phenomenon of IQ rise is highly persuasive that the treatment is causing the effect.  Correlation of treatment dose and IQ rise was most readily studied in the California subset. Among these prospectively studied ten public special education California children, IQ gains had a dose relationship. IQ gains averaged two standard deviations among patients treated four or five times a week versus one standard deviation for those treated once or twice a week. Treatment was usually for eight months. It appears to be highly significant that the nine California control and comparison treatment children, also blindly rated, had no IQ or CGAS gains.

IQ Rise Reported From Other Reflective Network Therapy ("Cornerstone") Sources:

Discussed above is a formerly autistic and retarded child who recovered from all symptoms which could be associated with those diagnostic labels. She gained 68 points from her first testable full score IQ, now has a full scale IQ of 148, and is socially and emotionally very well. Morris (2007) reports a long-term follow-up of the results of an Oklahoma team performing intensive psychoanalytically oriented therapy in the classroom [see chapter 3 of this book] During 1976 Morris and her colleagues began using an equivalent of the original "Cornerstone" method, establishing in-classroom intensive therapy programs within therapeutic preschools in several state and federally supported Community Mental Health Centers. At my request, Ms. Morris recently arranged a retesting of an autistic preschooler she selectively recalled had improved markedly.  She had treated him by an independently created variation of Reflective Network Therapy. The boy was difficult to test and had a starting full scale WPPSI IQ of 47 at age 4. There were no doubts about the diagnosis and his seeming mental retardation being part of autism. On a test comparable to the WPPSI, the WISC, his full scale IQ at age 8, two years after finishing his therapeutic nursery time, was 72. At age 9 years, 2 months, the child scored 91. At age 27 his full scale IQ was 125 and he was completing his university studies where he earned a B.A.. We are hoping that archives of the Oklahoma treatments will yield data of still other retested children, as did the Cornerstone in New York.  

A private Cornerstone program using Reflective Network Therapy in San Francisco tested and retested one child with pervasive developmental disorder.  He rose from a mentally retarded level of 58 to a near normal level of 69.  The Buenos Aires Cornerstone has completed re-testing of two treated children.  One had pervasive developmental disorder, with prominent autistic features.  The other was a girl with posttraumatic stress disorder as well as pervasive developmental delays.  Both had a full scale WPPSI-R IQ rise of 12 points, both from mentally retarded levels.  Both are no longer mentally retarded.

Discussion of Results

Reflective Network Therapy uses the whole network of persons in the child’s immediate classroom. It gives PDD children hundreds of orderly and deliberately structured and orchestrated affective experiences during the school year. These experiences, interpreted and verbalized by the analyst, often focus on the child’s behavior in relating to other classmates and to adults in the classroom. The child is literally led to develop a theory of the minds of those multiple others. In the process, the PDD children gain a cohesive view of their own selves as seen through the eyes and minds of others, and learn to care and feel for others, while modulating their own affective responses.

It appears the Reflective Network Therapy is an ecologically flexible environment and that  RNT is an ecologically effective mental health service delivery system for a variety of disturbed and developmentally delayed children. It appears that psychotherapy and parent guidance can be tailored precisely for a child and his family within various educational and therapeutic environments. It may be difficult for all educational and therapeutic teams and systems to sustain such an effort, but notable longevity of the Cornerstone method in various preschool applications has occurred in New York, California and Oklahoma. A large number of diagnostic categories of children have been helped. Children with diagnoses of the following disorders have responded well: Expressive and Receptive Language Disorder, Attention Deficit Disorder, Oppositional Defiant Disorder, Posttraumatic Stress Disorder and Overanxious Disorder.  One cure of an autistic child has been reported, and one cure of a child with Asperger’s disorder. Conspicuous among those very few we recall over the years who failed to show robust improvement is one severely autistic child who was never testable, who had almost no language development by age five, and who sustained almost no interest in interpersonal relations.

We think the whole series of surprising clinical plus cognitive successes would probably not have happened using ordinary methods. We believe that they required the Cornerstone Method of Reflective Network Therapy to make them happen. Reflective Network Therapy's in-classroom services involves a helpful synergy of educational influence with psychotherapy and parental guidance, creating an influential social network which targets and compensates for the PDD child’s most underdeveloped functions: tender affective communication, mentalizing of events and behavior, and modulation of social interaction. The same three functions of the social network, particularly the mentalizing function, are highly valuable in promoting more sophisticated forms of psychotherapy and guidance for the much more advanced overanxious, traumatized, or oppositional-defiant children who also have been seen to benefit robustly.

Most effective of all are the cognitive and behavioral results when a psychoanalytically oriented therapist adheres to a nearly daily schedule of interaction with the children in real life space, and meets very regularly and often with parents or primary caregivers.

Core features of the method we think are efficacious for children with PDD are the following:  individualization of the content of sessions which are tailored to the child’s own mental contents and immediate experiences; high frequency of in-classroom analytic treatment sessions; intensive interpretive work on resistance to socialization and learning in the real life-space; immediacy of the analyst’s and teachers’ mutual briefing and debriefing of the network of patient and his peers and caregivers in the classroom, similar networking of parental involvement in the classroom and via weekly parent guidance sessions with the teachers and monthly guidance sessions with the therapist.

In fact, play therapy literature shows that therapies for young children which lack any of these features - interpretive component, a focus on real life-space interpretation of resistance to learning and socializing, high frequency, or intensive involvement of parents─ are therapies which yield less or no IQ gain and clinical improvement. This is true for children with pervasive developmental disorders; it is true for children with the full range of other severely emotionally disabling disorders; and it is true for children stressed by foster care placement (Sokoloff 1959, Kliman, Friedman, Schaeffer and Pasquariella 1982). The highest IQ gains (two standard deviations) occur in the highest frequency of treatment groups, especially those run by psychoanalytic therapists as described by Kliman (1968, 1970, 1997) Hope (1999) and Zelman (1985, 1997).

Data from the present California cases, like the long-followed Kliman case and the Morris case from Oklahoma added together with the 42  cases from New York seem a coherent whole. They show the ability of Cornerstone teams in entirely different geographic and administrative settings –East Coast, West Coast, Middle America, in both public schools and private agencies-- to carry out the method with powerful clinical and cognitive effect. The recent research by Diaz Hope reported here improves on the significance of the earlier retrospective and uncontrolled Cornerstone method studies of Zelman, Samuels and Abrams (1985, 1994). As with Skeels’ (1939) work with institutionalized children, the earlier Cornerstone reporters generally found an average full scale IQ rise of two standard deviations. Some children clearly gained much more –as in the two long-followed cases of Kliman and Morris.  Skeels’ experiment, which encouraged close-attachment within an institution for adolescent mothers and their babies, showed an average gain of 27.5 points above control cases for the IQ of institutionalized mothers’ offspring, (n=13) versus a decline of 26.2 points in the control group (n=12). The various prior reports of IQ rise averaging up to two standard deviations are continued with our current data. Among their treated children: Zelman found a similar average rise of two standard deviations or 29.8 points with intensive (3 to 5 times a week) Cornerstone treatment while there was an average rise of one standard deviation or 11.7 points with less intensive RNT treatment and/or other treatments. For Zelman’s comparison group of 9 children who received only individual educational psychotherapy, without psychoanalytic work, there was only a rise of 4.22 points in IQ, much as in our 3 comparison and 6 control children, who had no IQ rise, and similar to Freeman’s (1927) and Kliman’s (1980) studies showing a 4 point rise among foster children assigned to middle class foster parents.

It is impressive to us that IQ rises reported have been occurring in culturally, linguistically, geographically and administratively diverse places including South America as well as on both U.S. coasts and in Oklahoma, each having different therapeutic teams and testers, and being found whether studied retrospectively or prospectively.

The California public and nonpublic special education use of Reflective Network Therapy has been clinically, educationally and scientifically rich. The data resulting has significance in a freestanding way, especially because of the availability in San Mateo of controls and comparison children, and the prospective method used. We expect the legal and political future will allows a contractual process between psychoanalytic therapists and school districts wishing to serve their severely disturbed preschoolers in the least restrictive way, as Cornerstone allows, right in their own schools rather than in pull-out therapy. Thus upcoming generations of psychoanalytic child therapists may have a significant public health contribution to make in providing classroom-based treatment. We look forward to more educationally impaired children being helped overcome mental health obstacles to their education, in this relatively unrestrictive way. There is now sufficient scientific data to justify treatment of more children with PDD in special education classrooms beginning at the preschool level, rather than depending mainly on aides, medications or pull-out therapies in offices, clinics, day-hospitals and residential facilities.

Still in question is whether public school systems will be enabled to make the administrative commitment to create sufficient stability to reliably use RNT's advantage for their children. The possibilities for future public school use of Reflective Network Therapy and consistent delivery of services to special needs children may benefit from the extensive efforts of the Blue Ribbon Commission on Autism in California at the state level.  This effort established three separate task forces comprised of highly knowledgeable experts who are working hard to streamline and centralize both information and services. Their deep recognition of the need for standardized screening and further training of pediatricians, teachers and parents and their commitment to finding reliable and replicable treatment models which are cost-effective is profoundly encouraging.

Sadly, in our experience, the lack of cohesive administrative consensus and procedures abruptly shut down a highly successful project in San Mateo. As soon as the responsible San Mateo special administrator (Parnes) retired, the six years of Reflective Network Therapy service was suddenly and irreversibly ended over a summer without communication by the new administrator to any of the participants.  After the fact of its termination, the new administrator informed us that she (incorrectly) thought that Cornerstone was a program only for traumatized children, and that she had no idea children with Pervasive Developmental Disorder were being served.  All the prospective beneficiary children had been reassigned. A similar administrative fate met a free RNT program in a special education classroom at the D’Avila San Francisco public school. When a collaborative, knowledgeable and enthusiastic administrator left, a new administrator was unresponsive and unreachable for six months.   As a result, a thriving program benefiting eight children and costing taxpayers nothing in addition to preexisting special education costs came to an end for lack of ability to inform staff and parents about the next school year’s enrollment. 

Thus, clinical feasibility was positively shown in two public school systems, but administrative stability was not achieved.  As a result of these experiences growing from a total of seven years working with public school systems, our agency suggests a change in the future.  There should be legally binding multi-year contractual collaboration agreements. The program and the children are vulnerable when stability is highly dependent on individual administrators.

We also look for improvements in types and scope of outcome measures.  A variety of means and strategies exist for judging child psychoanalytic outcomes. Reflective Network Therapy's evidence combines several such means and strategies. The data is robust for very good clinical and cognitive outcomes for children who are seriously emotionally disturbed and for those with pervasive developmental disorders. Neurophysiologic studies of the IQ rise process are now in order. It may be that SPECT, f-MRI and similar studies will show the brain effects of Cornerstone and other psychoanalytic therapies. We look forward hopefully now to new means of illuminating the neurophysiologic as well as psychological bases for the remarkable clinical and cognitive progress of our RNT patients who suffer brain-based disorders such as Pervasive Developmental Disorder.