Counselling Children

Young Peop!

baco
British Association for |
Counselling & Psychotherapy
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 The Handbook of
Counselling Children
and Young People

ST LANCASHIRE
Me EGE
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Los Angeles | London | Washington DC | New Delhi | Singapore

 The Handbook of
Counselling Children
and Young People
croited Jy

Sue Pattison | Maggie Robson |Ann Beynon

§SAGE pacc
nigasse Woe
 ®SAGE
Los Angeles |London |New Delhi
Singapore |Washington DC

SAGE Publications Ltd Preface © Mike Shooter Chapter 15 © Dee C. Ray

1 Oliver’s Yard Introduction © Sue Pattison, Chapter 16 © Katherine
55 City Road Maggie Robson, Ann Beynon McArthur, Mick Cooper
London EC1Y 1SP Chapter 1 © Simon Gibbs, Chapter 17 © Peter Jenkins
Wilma Barrow, Richard Parker Chapter 18 © Peter Jenkins
SAGE Publications Inc. Chapter 2 © Graham Bright Chapter 19 © Sue Pattison,
2455 Teller Road Chapter 3 © Sue Kegerreis, Divine Charura,
Thousand Oaks, California 91320 Nick Midgley Tom McAndrew
Chapter 4 © Paul Stallard Chapter 20 © Maggie Robson
SAGE Publications India Pvt Ltd Chapter 5 © Belinda Harris Chapter 21 © Caryl Sibbett,
B 1/l 1 Mohan Cooperative Industrial Area Chapter 6 © Niki Cooper, Cathy Bell
Mathura Road Kelli Swain-Cowper Chapter 22 © Caryl Sibbett,
New Delhi 110 044 Chapter 7 © Lisa Gordon Clark Cathy Bell
Chapter 8 © Barbara Smith, Chapter 23 © Beverly
SAGE Publications Asia-Pacific Pte Ltd Kaye Richards, Toby Quibell Turner-Daly
3 Church Street Chapter 9 © Ani de la Prida, Chapter 24 © Erica Allan,
#10-04 Samsung Hub Wendy Brown Elizabeth K. Hughes,
Singapore 049483 Chapter 10 © Dave Stewart, Daniel Le Grange
Edith Bell Chapter 25 © Barbara Smith,
Chapter 11 © Mark Prever Sue Pattison, Cathy Bell
Chapter 12 © Sally Ingram, Chapter 26 © David Exall
Maggie Robson Chapter 27 © Peter Pearce, Ros
Chapter 13 © Penny Leake, Sewell, Karen Cromarty
Ann Beynon Chapter 28 © Sue Pattison,
Chapter 14 © Peter Pearce, Terry Hanley,
Gwen Proud, Ros Sewell Olga Pykhtina

Editor: Susannah Trefgarne First published 2015

Assistant editor: Laura Walmsley
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 Contents

List of Figures and Tables

List of Abbreviations
About the Editors and Contributors
Foreword ~ Mike Shooter
Acknowledgemetts

Editors Introduction — Sue Pattison, Maggie Robson and Ann Beynon

Part1 Theory and Practice Approaches

1 Child Development and Attachment ~ Simon Gibbs, Wilma Barrow
and Richard Parker
Child and Young Person-Centred Approach - Graham Bright
Psychodynamic Approaches ~ Sue Kegerreis and Nick Midgley
Cognitive-Behavioural Therapy — Paul Stallard
Gestalt - Belinda Harris
OH
NY
W
UW Becoming an Integrative Practitioner — Niki Cooper and
Kelli Swain-Cowper
Play Therapy — Lisa Gordon Clark
Other Creative Approaches - Barbara Smith, Kaye Richards
and Toby Quibel)

Part2 Counselling Practices and Processes 127

Referrals and Indications for Therapy — Ani de la Prida

and Wendy Brown 129
Preparation for Therapy: Beginnings ~ Dave Stewart and Edith Bell 152
The Therapeutic Alliance and Counselling Process - Mark Prever 170
Therapeutic Skills - Sally Ingram and Maggie Robson 183
Supervision ~ Penny Leake and Ann Beynon 196
vi Contents

14 Group Work - Peter Pearce, Gwen Proud and Ros Sewell 212
15 Endings — Dee C. Ray 279
16 Evaluating Counselling - Katherine McArthur and Mick Cooper 244

Part 3 Practice Issues 297

17 Law and Policy — Peter Jenkins 259

18 Ethics — Peter Jenkins 29.
19 Diversity - Sue Pattison, Divine Charura and Tom McAndrew 294
20 Bereavement - Maggie Robson 308
21 Depression - Caryl Sibbett and Cathy Bell 320
22 Self-Harm and Suicide - Caryl Sibbett and Cathy Bell 332
23 Sexual, Physical and Emotional Abuse - Beverly Turner-Daly S51
24 Eating Disorders — Erica Allan, Elizabeth K. Hughes and
Daniel Le Grange 368

Part4 Practice Settings 381

Zo Health and Social Care Services - Barbara Smith,
Sue Pattison and Cathy Bell 383
26 Third and Non-Statutory Sectors - David Exall 401
LT School and Education Settings - Peter Pearce, Ros Sewell
and Karen Cromarty 415
28 Extending Practice: New Horizons - Sue Pattison, Terry Hanley and
Olga Pykhtina 427

References 442
Index 492
 List of Figures and Tables

Figures

2.1 A way of being 24

4.1 Reinforcing behaviours DZ
6.1 The interpersonal world of the infant 88
8.1 Mandala images 116
9.1 Puzzle grid : 139
10.1 Seven key tasks of the preparation-for-therapy map LD
10.2 Bronfenbrenner’s ecological model of development 163
28.1 Expressing emotions on the digital tabletop 438

Tables

2.1 Rogers’ seven stages of process 27

8.1 An example of a ‘bio-poem’ VA
9.1 CAMHS’ four-tier system 130
9.2 When a CAMHS referral might be appropriate 144
16.1 Most frequently used tools for evaluating counselling with
children and young people 249
17.1 Legal sources and their application to counselling practice 264
17.2 School-based counselling: Comparison of current and potential
future patterns of counselling practice 265
17.3. Stepped care model for the CYP-IAPT service 267
28.1 Some soft encounters with technology within therapeutic work 429
28.2 Common forms of online one-to-one counseling. 430
28.3 Reasons that online counselling services for young people
cite for their development 431
 List of Abbreviations

AA Alcoholics Anonymous
ADHD Attention Deficit Hyperactivity Disorder
APT Adolescent-Focused Therapy
AN Anorexia Nervosa
APA American Psychiatric Association
ASA Adoption Support Agency
ASCA American School Counsellor Association
ASD Autistic Spectrum Disorder
ASLI Association of Sign Language Interpreters
BACP British Association for Counselling and Psychotherapy
BACP CYP British Association for Counselling and Psychotherapy Children and
Young People
BAPT British Association of Play Therapists
BN Bulimia Nervosa
BPS The British Psychological Society
BSL British Sign Language
BTE Behind-the-ear
CAF Common Assessment Framework
GASE Child and Adolescent Self-harm in Europe
CAMHS Child and Adolescent Mental Health Services
CBT Cognitive-Behavioural Therapy
CCS Catholic Children’s Society
CORC CAMHS Outcome Research Consortium
CORE-OM Clinical Outcomes in Routine Evaluation - Outcome Measure
CORS Child Outcome Rating Scale
CPS Crown Prosecution Service
CSRS Child Session Rating Scale
GYP Children and Young People
GYPTAPT Children and Young People’s Improving Access to Psychological Therapies
GYP PRN Children and Young People Practitioner Research Network
 List of Abbreviations ix

DCHP Deaf Children of Hearing Parents

DfE Department for Education
DoH Department of Health
DPM Dual Process Model
DSM-5 The Diagnostic and Statistical Manual of Mental Disorders
EBD Emotional and Behavioural Difficulties
EBP Evidence-Based Practice
EDNOS Eating Disorder Not Otherwise Specified
FBT Family-Based Treatment
GCSE General Certificate of Secondary Education
GP General Practitioner
HEPC Health and Care Professionals Council
HI Hearing Impaired
IAPT Improving Access to Psychological Therapies
IPT Interpersonal Therapy
IQ Intelligence Quotient
LA Local Authority
LMS Local Management of Schools
LSCB Local Safeguarding Children Board
MCE Manually Coded English
MHF Mental Health Foundation
MUPS Medically Unexplained Physical Symptoms
NAYPCAS National Association of Young Peoples Counselling and Advisory
Services
NDPT Non-directive Play Therapy
NHS National Health Service
NICCY Northern Ireland Children’s Commissioner for Children and Young
People
NICE National Institute for Health and Clinical Excellence
NSPCC National Society for the Prevention of Cruelty to Children
OCD Obsessive Compulsive Disorder
Ofsted Office for Standards in Education, Children’s Services and Skills
ORS Outcome Rating Scale
PACE Playfulness Acceptance Curiosity and Empathy
PBRN Practice-Based Research Network
PBE Practice-Based Evidence
PCA Person-Centred Approach
PHA Public Health Agency
PTSD Post-Traumatic Stress Disorder
RBCSB Rochdale Borough Safeguarding Children Board
x List of Abbreviations

RCT Randomised Controlled Trial

SAN Sub-threshold Anorexia Nervosa
SATs Standard Assessment Tests
SBPCC School-Based Person-Centred Counselling
SBN Sub-threshold Bulimia Nervosa
SCIE Social Care Institute for Excellence
SCoPReNet School-Based Counselling Practice Research Network (now CYP PRN)
SDQ Strengths and Difficulties Questionnaire
SE Signed English
SEE Seeing Exact English
SENCO Special Educational Needs Co-ordinator
SIGN Scottish Intercollegiate Guidelines Network
SPT Individual Supportive Psychotherapy
SSE Sign Supported English
TaMHS Targeted Mental Health in Schools
UKCP United Kingdom Council for Psychotherapy
UNCRC United Nations Convention on the Rights of the Child
UPR Unconditional Positive Regard
VA Voluntary Action
WAG Welsh Assembly Government
WHO World Health Organisation
YCORS Young Child Outcome Rating Scale
YIACS Youth Information Advice Counselling and Support Services
YP-CORE Young Person's Clinical Outcomes in Routine Evaluation
ZPD Zone of Proximal Development
 About the Editors and
Contributors

Sue Pattison is Lecturer in Education and Counselling at Newcastle University and

has strong experience of working in all four nations of the UK, Africa, the Middle East
and Asia. She is Director of the Integrated PhD in Education and Communication. Her
main research interests are the social and emotional health and well-being of children
and young people and she is an accredited counsellor (BACP) in practice as a therapist
and supervisor and trainer.

Maggie Robson is a senior teaching fellow at Keele University where she was respon-
sible for the professional counsellor training programmes to Master’s level. She is also
a qualified play therapist and has a special interest in working with, and researching,
children’s bereavement. She has taught play therapy programmes in the UK, Kenya and
the US and trained the first play therapy supervisors in Kenya. In her free time she is a
bit of a water baby and enjoys sailing, canoeing and swimming. She also loves walking
and bike riding and the occasional glass of wine!

Ann Beynon has worked as a teacher, counsellor, trainer and service manager for the
last 40 years. She is convinced of the eclectic role of the counsellor in the development
of effective learning relationships in educational and community settings. This convic-
tion led her to focus on ways of developing integrated time for reflection, for teachers.
To this end, she researched the application of a non-management therapeutic model
of supervision within the educational context. Based on positive findings from this
research, she has now established a service which provides regular Structured Time for
Reflection, for head teachers and their staff.

Erica Allan has a background in psychology and is working as research assistant within
the Eating Disorders Program at The Royal Children’s Hospital, Melbourne, Australia.
xii About the Editors and Contributors

As part of her involvement in the Eating Disorders Program, Erica has been involved in
the management of a clinical trial for adolescents with anorexia nervosa.

Wilma Barrow is an educational psychologist working in Scottish Borders Council.

She works with children and young people, their families, schools and other agen-
cies to support learning and wellbeing through the application of psychology. She
has been involved in postgraduate training of educational psychologists for ten years
and is currently an Academic and Professional Tutor on the DAppEdPsy Programme
at Newcastle University. She is interested in the role of dialogue within all aspects of
educational psychology practice and particularly in its transformative potential for
teaching and learning and participative practices.

Cathy Bell has worked with children and young people in statutory social services
settings, within a voluntary organisation and in a residential setting in the developing
world. While working with the NSPCC, Cathy set up the school counselling services
in Northern Ireland, now Independent Counselling Services for Schools (ICSS) funded
by the Northern Ireland Department of Education. Cathy is currently the ICSS coor-
dinator, committed to advocating for a rights-based approach to services for children.
Since September 2012 Cathy has been chair of the BACP’s Children and Young People’s
Executive and has recently been awarded a Fellowship with BACP.

Edith Bell has worked for 14 years in schools and community practice with children,
young people and parents. She is the Director of Counselling for Familyworks and has
undertaken specialist CYP research and training as part of her CBT Master’s. She has
written and developed undergraduate courses and taught extensively at undergradu-
ate and postgraduate levels, as well as in the voluntary and statutory sectors. She is a
BACP Accredited Counsellor. She sits on the BACP CYP Executive Committee and
was a member of the BACP Expert Reference Group in developing national compe-
tence standards for CYP counsellors.

Graham Bright is Senior Lecturer in Childhood and Youth Studies and Youth and
Community Work at York St John University. He was formerly a lecturer in coun-
selling on the Teesside University franchised FdA and BA (Hons) Counselling at
Darlington and Redcar and Cleveland colleges, and is co-editor (with Gill Harrison) of
Understanding Research in Counselling (Learning Matters/SAGE, 2013). His PhD study
with Durham University is provisionally entitled: ‘The Role of Personal Narratives,
Vocation and Personal and Professional Development in the Formation of Youth Workers
and Counsellors: A Comparative Narrative-Interpretative Phenomenological Inquiry’.

Wendy Brown is an experienced trainer, supervisor and counselling practitioner hav-

ing worked in charitable and social care settings, as well as private practice. Currently
 About the Editors and Contributors xiii

practising as an adult and young persons’ counsellor and supervisor, Wendy also works
within the care system, working systemically to support professionals around the child.
Wendy runs groups, offers consultations, carer and child work, and develops and deliv-
ers trainings for social work staff and foster carers with the aim of helping understand
behaviours and create attachment between the child and the carer. Wendy is a BACP
Accredited Counsellor and has been a member of the BACP CYP Executive Committee
since 2010, and Deputy Chair since 2012.

Divine Charura is a Senior Lecturer in Counselling and Psychotherapy at Leeds

Metropolitan University. He is an adult psychotherapist in the NHS, voluntary sector,
and in private practice. Divine is also an independent trainer, supervisor, and coach.
He contributed various papers and to various books. His latest book contributions are
two books on the therapeutic relationship: The Therapeutic Relationship Handbook:
Theory and Practice (McGraw-Hill Open University Press, forthcoming, edited with
Stephen Paul) and An Introduction to the Therapeutic Relationship in Counselling and
Psychotherapy (SAGE, 2015, with Stephen Paul). In his spare time Divine is a lover of
art, photography, music and outdoor pursuits.

Mick Cooper is a Professor of Counselling Psychology at the University of Roehampton, a

chartered counselling psychologist, and a fellow of the British Association for Counselling
and Psychotherapy. He has been involved in the evaluation of counselling with children
and young people since 2003, leading on a range of quantitative and qualitative studies.
Mick was Clinical Lead on the Counselling MindEd e-learning programme (www.minded.
org.uk), and is author of a range of texts on humanistic and existential approaches to ther-
apy. These include Working at Relational Depth in Counselling and Psychotherapy (SAGE,
2005, with Dave Mearns) and An Existential Approach to Counselling and Psychotherapy
(SAGE, 2015). Mick lives in Brighton with his partner and four children.

Niki Cooper is Programme Leader for professional qualifications at Place2Be, which

is the leading UK provider of school-based emotional and mental health support ser-
vices, supporting 75,000 children in 200 schools. She is co-author of the Place2Be
Postgraduate Diploma in Counselling Children in Schools and has also overseen the
development of a comprehensive professional qualifications pathway from Level 2 to
MA. Before joining Place2Be in 2002, she was a community-based counsellor in South
London for London Marriage Guidance and a secondary school counsellor.

Karen Cromarty works for the British Association for Counselling and Psychotherapy
and is their Senior Lead Advisor. In her role Karen works strategically with opinion form-
ers, academics, governments, and service managers in all sectors, across all of the UK,
to try to ensure that counselling services for children and young people are accessible,
effective and based upon the most recent research. Karen is an experienced counsellor,
xiv About the Editors and Contributors

supervisor, trainer and researcher, and in her spare time has worked for r
Chair of Governors of a large successful secondary school in the North Ez

Ani de la Prida is a counsellor, lecturer and supervisor. She has work

the DipHE in Counselling Children and Young People in her role as |
at Anglia Ruskin University and Programme Leader at Renew Counse.
based in Essex and East London. Ani is a person-centred therapist and «
who has worked with children and young people in schools, exclusion ]
care and drug treatment programmes since 1999. She has also worked a
for a number of years. Her special areas of interest include person-centr
looked-after children and digital media in therapy having recently com]
into the therapeutic use of digital media for her MA in Counselling & Ps
the University of East London. Ani was an author on the Counselling Min
programme (www.minded.org.uk). In addition to her current work in p
Ani is also an active member of the BACP Professional Education Develo
an Examiner for ABC Awards and Chief Examiner for AQA Counselling

David Exall studied counselling at Lewisham College. He has worked w

the voluntary sector for 14 years and has worked in schools, further and
tion as a trainer and counsellor. He is a certified supervisor. David joinec
School Project Manager in 2001 before becoming a full-time trainer, deli
to staff, volunteers, professionals working with children and families, anc
sellors. He is currently Head Trainer and continues to deliver training, 1
ing new programmes and holding overall responsibility for the Quality
training. David continues to work therapeutically within schools and ci
with young people in a secondary setting.

Simon Gibbs is Reader in Educational Psychology at Newcastle Univer

Programme Director for the Doctorate in Applied Educational Psycholos
the Education Section. Before that he worked as a secondary school teac
Educational Psychologist in Cleveland, Hartlepool and latterly as Senic
Psychologist in North Yorkshire. He has an MEd in Human Relations, a1
Psychology (Education) and a PhD in Psychology. His current research in
the effects of teachers’ ‘Efficacy Beliefs’ and attributions on their practice
opment of inclusion. He is also General Editor of Educational and Child

Lisa Gordon Clark. After motherhood and six years as a primary sch
the London Borough of Hounslow, Lisa trained as a play therapist at
in the mid-1990s and has been in private practice ever since, recent
her therapeutic base from London to Wiltshire. For over a decade she
the Board of Directors of BAPT, chairing the Communications and Pt
 aa a ae ES IT SS es ia

About the Editors and Contributors XV

She remains Editor of the annual British Journal of Play Therapy. Since
aught on the Play Therapy MA at the University of Roehampton where
ior Lecturer and Programme Convener.

the Programme Director for the Doctorate in Counselling Psychology at

f Manchester. He is Editor of the British Psychological Society's Counselling
ew, the lead author of Introducing Counselling and Psychotherapy Research
> lead editor of Adolescent Counselling Psychology (Routledge).

5 is associate professor in the School of Education at the University

, where she is responsible for undergraduate and postgraduate taught
nd led the Master’s in counselling children and young people for sev-
nda’s original interest in counselling began through her experience of
1odern languages teacher in an inner city school in very challenging
Following training in person-centred counselling and then Gestalt psy-
established therapeutic services for students and their families, and
with teachers and school leaders to enhance their Capacity to create
ig relationships with the most vulnerable young people. This focus on
between education and therapy is central to her work and research. She
videly, and recently conducted a scoping review of school counselling
s for the BACP/DoH MindEd project. Belinda is a UKCP Registered
» an ICF Certified Professional Coach and has a small practice working
id young adults. She is assistant editor of the British Gestalt Journal.

ughes is a research fellow with the Eating Disorders Program at The

; Hospital and University of Melbourne, Australia. She received her PhD
om Monash University and holds honorary positions with the Murdoch
rch Institute and the School of Psychology and Psychiatry at Monash
lughes’ research focuses on the treatment of eating disorders in adoles-
ly family-based treatment for anorexia nervosa. Her research interests
norbidity in eating disorders, emotion regulation, and family systems.

the Director of Counselling at Durham University. She is a qualified

, child and adolescent counsellor, supervisor and trainer, with 15 years’
anaging counselling services. During that time she has served as the
the BACP’s children and young people’s division, as well as their journal
contributor to the MindEd program with a focus on adolescent devel-
chment experiences and how these impact on their well-being. Sally is
umitted to the psychological and emotional well-being of children and
d was awarded commitment to students in 2014 by the Student Union.
> she enjoys hillwalking, photography and independent cinema.
Xvi About the Editors and Contributors

Peter Jenkins is Senior Lecturer in Counselling at Manchester University. He has been

a member of both the BACP Professional Conduct Committee and the UKCP Ethics
Committee. He has extensive experience of training counselling practitioners and
organisations on children’s rights and legal aspects of therapy, and has researched and
published widely on this topic. His publications include Counselling, Psychotherapy and
The Law (2nd edn, SAGE, 2007) and, as co-author with Debbie Daniels, Therapy With
Children (2nd edn, SAGE, 2010) plus a training DVD on ethics and law in counselling
children, ‘A Confidential Space’ (Counselling DVDs/University of Wales).

Sue Kegerreis is Director of the Centre for Psychoanalytic Studies at the University of
Essex, where she is a Senior Lecturer and Course Director for the MA Psychodynamic
Counselling. She trained as a teacher; as a child and adolescent psychotherapist at the
Tavistock; and later as an adult psychoanalytic psychotherapist with the Lincoln. She
has practised privately and in a range of other settings: school, hospital and CAMHS, as
well as teaching on many courses, both clinical and applied. She worked for many years
as a school counsellor. She has published widely in professional journals and her book
Psychodynamic Counselling with Children and Adolescents was published in 2010.

Daniel Le Grange is Professor of Psychiatry and Behavioral Neuroscience and

Director of the Eating Disorders program at The University of Chicago Medicine. Dr
Le Grange obtained his PhD in Psychology at the Institute of Psychiatry, University of
London and completed postdoctoral training at the University of London as well as
Stanford University School of Medicine, California. Dr Le Grange’s research interests
focus primarily on psychosocial treatment trials for adolescents with eating disorders.
His peer-reviewed articles concerning these and other related topics number more
than 150, and are published in prestigious journals such as the American Academy for
Child and Adolescent Psychiatry, American Journal of Psychiatry, Archives of General
Psychiatry, Archives of Pediatrics and Adolescent Medicine, and Pediatrics. Dr Le Grange
has co-authored 7 books, more than 40 book chapters, and more than 150 abstracts
and presentations for national and international scientific meetings. Dr Le Grange
is a Fellow of the Academy for Eating Disorders, a Member of the Eating Disorders
Research Society, Associate Editor for the Journal of Eating Disorders, serves on the edi-
torial boards of the European Eating Disorders Review and the International Journal of
Eating Disorders. Dr Le Grange is currently Principal Investigator on several National
Institute for Mental Health-funded treatment studies in the United States.

Penny Leake started her professional life as a teacher, but later retrained as counsellor,
social worker and clinical supervisor. She began counselling in 1980, and since 1992
has specialised in working with children and young people. She spent many years as
practitioner, manager and clinical supervisor for therapeutic services in the North East
 About the Editors and Contributors xvii

of England, in both the statutory and voluntary sectors. She is BACP Senior Accredited
as both Supervisor and Counsellor, and now works freelance in Derbyshire. Her super-
visees have included several CAMHS workers and play therapists. She strongly believes
that workers have to feel well supported themselves if they are to support others.

Tom McAndrew With over 10 years’ experience in education in British and interna-
tional institutions, Tom McAndrew has spent most of his teaching career working with
deaf children. He holds an MA in Deaf Education from Leeds University and is a quali-
fied Teacher of the Deaf. Passionate about British Sign Language, he is a keen travel-
ler and aspires to build bridges between the hearing and deaf cultures, and empower
young deaf and hard of hearing children from around the world. In 2011 he ran the
London Marathon raising money for Deaf Child Worldwide. He has two young chil-
dren and currently lives and works in Kuala Lumpur with his family.

Katherine McArthur is a research associate at the University of Strathclyde, currently

undertaking action research on mentoring for looked after children. She practices
counselling with adults in a research setting, and with young people in a Glasgow
secondary school, using a humanistic approach. School-based counselling is her
main research interest and the focus of her PhD from the University of Strathclyde.
In 2013 she was awarded the British Association for Counselling and Psychotherapy’s
Outstanding Research Award for a pilot randomised controlled trial of school-based
counselling. Her previous research interests include the needs and rights of disabled
children in the UK child protection system. She is a core group member of the Children
and Young People Practice Research Network developed by the British Association for
Counselling and Psychotherapy, and a member of Psychotherapists and Counsellors
for Social Responsibility. In 2012, she co-edited a school-based counselling symposium
edition of the British Journal of Guidance and Counselling.

Nick Midgley is a child and adolescent psychotherapist and a lecturer at University

College London, where he is Course Director of the MSc in Developmental Psychology
and Clinical Practice, and Academic Director of the DPsych in Child and Adolescent
Psychotherapy. He has written and edited several books, including Reading Anna Freud
(Routledge, 2013) and Child Psychotherapy and Research (Routledge, 2009).

Richard Parker is an educational psychologist working in Newcastle University and a

local authority. He has worked as an educational psychologist for more than 30 years,
holding specialist and management posts in a number of local authorities and with
responsibilities from pre-school to Further Education. Richard's interests focus on pro-
fessional reflection and learning, how professionals’ views affect their practice, develop-
ing professional supervision and the impact on life course development of relationships.
xviii About the Editors and Contributors

Peter Pearce is Head of the Person Centred Department at Metanoia Institute where,
amongst other trainings, he runs a Post Qualification, Conversion Diploma from Adult
to Adolescent and School Counselling. Peter has provided person-centred counselling
with young people within NHS and education settings since 1989. He has worked as
a school counsellor in secondary school settings since 1999. He has a 17-year-old son
and four small daughters.

Mark Prever was a counsellor, trainer and supervisor. He was lead professional for
Every Child Matters at Yardleys School in Birmingham; a Chair of Open Door Youth
Counselling Centre; former chair of the BACP’s Counselling Children and Young
People division and a lecturer at Worcester University which he had hoped to carry on
through his retirement. Mark wrote regularly and his books include Mental Health in
Schools: A Guide to Pastoral & Curriculum Provision (SAGE, 2006) and Counselling and
Supporting Children and Young People (SAGE, 2010). Mark passed away in March 2013.

Gwen Proud has been employed in educational organisations for the majority of her
working life including being a secretary in local government and independent schools,
counselling in secondary schools in the North East of England for a children’s char-
ity and later for the local education authority. She completed a Master's Degree in
Counselling at Durham University, a Doctorate in Counselling Studies at the University
of Manchester, and is a BACP Accredited Counsellor. Gwen has divided her working
practice between primary care and school settings and is experienced in working thera-
peutically with groups of children of secondary school age.

Olga Pykhtina is doctoral student at Newcastle University. Under the supervision of

Dr Sue Pattison and Professor Patrick Olivier, she is investigating how primary school
children and therapists can use digital technology at different stages of play therapy.
Her study aims to establish a paradigm of understanding as to what are the advantages
and barriers for the use of multi-touch technology in therapeutic context. She is explor-
ing whether there is a place within non-directive play therapy for the designed in her
research application Magic Land. Her main research interest is the impact of digital
toys for child-therapist therapeutic alliance.

Toby Quibell is a school teacher and drama therapist. In 1993 he set up The Learning
Challenge, a charity that worked for 20 years in the most deprived schools in the North
East of England. Over this time Toby initiated, piloted and tested a range of therapeutic
group interventions designed to dovetail into the delivery of the school curriculum.
Working between 2008 and 2010 with a team of specially trained teaching staff in two
large secondary schools he co-ordinated the delivery of a combined package of thera-
peutic support as a timetabled slot for all Year 7 and Year 9 children.
 About the Editors and Contributors xix

Dee C. Ray is Distinguished Teaching Professor in the Counseling Program and

Director of the Child and Family Resource Clinic at the University of North Texas. Dr
Ray has published over 85 articles, chapters and books in the field of play therapy. Dr
Ray is author of Advanced Play Therapy: Essential Conditions, Knowledge, and Skills for
Child Practice, Child Centered Play Therapy Treatment Manual, Group Play Therapy and
Child Centered Play Therapy Research. She is current editor of the Journal of Child and
Adolescent Counseling and former editor of the International Journal of Play Therapy.
Her research interests focus on effectiveness and mediator variables in play therapy.

Kaye Richards is Senior Lecturer in Outdoor Education at Liverpool John Moores

University and a Chartered Psychologist of the British Psychological Society. She has
worked and published widely across the areas of outdoor education, sport, adventure
therapy, and counselling and psychotherapy, with a specialist focus on young people.
She is a longstanding member of the Adventure Therapy International Committee,
Chair of the Special Interest Group of Outdoor and Adventure Therapy for the Institute
for Outdoor Learning and was launch editor of the academic Journal of Adventure
Education and Outdoor Learning.

Ros Sewell is Primary Tutor for the Post Qualification Conversion Diploma from Adult
to Adolescent and School Counselling at Metanoia and a BACP Accreditation Assessor.
She has provided person-centred counselling with young people within NHS and edu-
cation settings since 1989 and worked as a school counsellor in secondary school set-
tings since 1997. She has two teenage children.

Caryl Sibbett is a Registered Member MBACP, a BACP Senior Accredited Counsellor/

Psychotherapist and a BACP Fellow. Caryl is a Trustee of the BACP. She is also an Art
Psychotherapist (HCPC Reg.). As an experienced trainer, she is also a Fellow of the
Higher Education Academy and Chair of the Counselling Children and Young People
Training Consortium (NI). Caryl works in private practice and sessionally in a Health
and Social Care context. She supervises for a wide range of organisations providing
services for children and young people. An experienced researcher, she has published
and presented nationally and internationally.

Barbara Smith is Assistant Clinical Lead in the Children and Adolescent Mental
Health Service at Alder Hey Children’s Hospital, a UKCP registered Child and Adult
Psychotherapist and a BACP (Senior) Accredited Counsellor. She works in private
practice offering individual and group psychotherapy. She spent many years delivering
counselling training, supervises practising counsellors and is a member of British Red
Cross psychosocial support (disaster) team. She has a strong research background in
cross-cultural psychotherapy having undertaken her doctoral research in the Maldive
xx About the Editors and Contributors

Islands and has published in the areas of anti-discriminatory practice, adventure ther-
apy, children’s self-esteem and working creatively.

Paul Stallard is Professor of Child and Family Mental Health at the University of Bath
and Head of Psychological Therapies (CAMHS) for Oxford Health NHS Foundation
Trust. He trained as a clinical psychologist and works within a specialist child mental
health team where he leads a Cognitive-Behaviour Therapy (CBT) clinic for children
and young people with emotional disorders of anxiety, depression, OCD and PTSD. He
is an active researcher and a leading figure in the development of CBT with children.
He is the author of the much acclaimed Think Good Feel Good: A Cognitive Behaviour
Therapy Workbook for Children and Young People.

Dave Stewart is a BACP Accredited Counsellor—Psychotherapist and registered social

worker. With over 20 years’ experience in therapeutic work with children, young
people and families, Dave first trained and worked as a music therapist. He later
worked as a child therapist in a community setting before taking up the post of senior
trauma counsellor in the children’s charity Barnardo's. Dave currently leads a team of
Barnardo's school-based counsellors which won the BACP award for ‘Innovation in
Counselling and Psychotherapy’ in 2012. His special areas of interest include therapy
with younger children, children and young people with special needs and outcome-
informed practice. Dave has many years’ experience as a trainer and has presented
and published widely. The last 5 years have seen him develop a relational, outcome-
informed model of counselling practice specific to younger children.

Kelli Swain-Cowper is an HPC accredited art therapist, Co-Author and Lead Tutor of the
Postgraduate Diploma for Counselling Children in Schools. She trained at NYU in New
York City and specialised in working with children and adolescents at St. Luke's Roosevelt
Child and Family Institute. In New York, she supervised, worked in and developed arts
therapies programs in schools, clinics, emergency refuges and children’s inpatient hospi-
tals. Moving to London in 2001, she began work with Place2Be, project managing, super-
vising and training and maintains clinical work in schools and a private practice.

Beverly Turner-Daly is a qualified social worker, counsellor and clinical supervi-

sor with over 25 years experience in the field of post-abuse counselling and therapy.
She works part-time as Senior Lecturer at Northumbria University where she is the
Programme Leader for the Post-Qualifying Child Care Award and involved in several
research projects focusing on child abuse and its impact on workers. Beverly also works
as an independent supervisor, trainer and consultant, providing training and supervi-
sion to a wide-range of professionals who work with children and families.
 Foreword
Mike Shooter

Round about my time of life, you start asking yourself what kept you in your career for
so long — in my case, 30 years as a child and adolescent psychiatrist in the NHS. Well,
here are a few good reasons why.
Working with children and young people is more directly about human beings and
their lives than any other occupation I know. Rarely does the stethoscope, a packet of
tablets or any therapeutic defence get in the way. And the corollary of that is that they
present the therapist with the most difficult of challenges. Who are you? How did you
resolve that in your own childhood? And can you cope with what I am about to throw
at you from mine?
Answering those questions requires the most eclectic of approaches. Children, in
my experience, rarely compartmentalise their lives. What misery they face in one bit
spreads throughout. To tackle it, we must offer a package of approaches, tailored to the
child’s needs, not cram the child into whatever ‘ism suits us best. And that package, in
turn, should be set within a holistic, multidisciplinary context that tackles the problems
from every angle —- home, school, peer group and community. The very process of
working together can be healing to a shattered life.
Diagnosis, of course, may be important. But what children and adolescents may need
most is the space to explore their life-story, where it began, where it might have gone
wrong, and to re-tell it, with a different ending. All within the safety of the therapeutic
structure. And that gives the therapist space too for a responsible creativity. Human
beings again - exploring the problem together by whatever seems appropriate, not an
all-powerful adult doling out treatment to a passive recipient.
And that means that this is the age group in which we can make most difference to
their lives. By helping children and young people to voice their individual needs and their
views of how services might best be organised to satisfy them, we can empower them to
solve their life problems as they recur. For those too afraid, too downtrodden or too disa-
bled, we can raise a voice for them until they are strong enough to find their own.
XXii Foreword

Finally, if all that sounds too glib, what kept me in the business most of all, was the
element of surprise. I never knew from one day to the next what a child or adolescent
might present me with, what fresh insights they might offer and how I might learn from
them as much as I might offer in return. In the end, however skilled the consultants
under whom I learned my trade, however skilled the supervisors I have used to guide
me through the most difficult of situations, it is children and young people who have
taught me most of what I know.
So why have I shared all those reasons with you? Because this book epitomises every
one of them - the principles, the knowledge, the experience, the skills and techniques,
and the sheer excitement of working with children and young people, and the chal-
lenges it entails. I wish Id had it to hand when I started out those 30 years ago. Now it
passes my ultimate test - ‘damn, I wish Id written that myself!’
 Acknowledgements

We would like to thank all the contributors in this book for their generosity in sharing
their knowledge, skills and experience for the benefit of children and young people
worldwide and their counsellors.
We wish to remember Mark Prever with great respect and thank his brother for
facilitating the publishing of Mark’s chapter, sadly Mark died soon after writing it.
We would like to acknowledge the professionalism and editorial help given by Rachel
Burrows, Laura Walmsley and Susannah Trefgarne from SAGE and for their patience
and expertise.
We are grateful to BACP, the MindEd team and particularly, the Children and Young
People’s Committee for their ongoing support and the book reviewers for their valuable
feedback.
Finally, it is important to acknowledge the relationships forged through the process
of writing this book, between the authors and the editorial team. We have learnt much
from each other.
Sue Pattison
Maggie Robson
Ann Beynon
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 Editors’ Introduction
Sue Pattison, Maggie Robson and Ann
Beynon

The ideas and impetus for this book came together as a response to the growing need
for high quality training and reference resources in the expanding field of coun-
selling children and young people. This book was waiting to be written - we had
discussed producing a unique resource for counsellors of children and young people
for some time. The opportunity to ‘walk the walk came when we were approached
by SAGE as members of the British Association for Counselling and Psychotherapy’s
Children and Young People Committee. The timing was key, as BACP were develop-
ing the Counselling Competencies and the MindEd e-learning resources. The British
Association for Counselling and Psychotherapy (BACP) have developed a set of compe-
tencies for therapists who work with young people. These are available on their website
(www.bacp.co.uk/). These competencies were developed as humanistic competencies,
but the further development of core and generic competencies, in our view, detail the
general therapeutic skills relevant to all practitioners working both with children and
young people, regardless of theoretical orientation. Some of the issues identified in
these core competencies are explored in detail within this handbook, reflecting the
importance of these areas when working therapeutically with children and young
people. Competencies identified by BACP (2014) include knowledge of child and fam-
ily development and transitions, and knowledge and understanding of mental health
issues. Knowledge of legal, professional and ethical frameworks is considered essential,
including an ability to work with issues of confidentiality, consent and capacity. BACP
(ibid.) suggest that therapists need to be able to work across and within agencies and
respond to child protection issues. In addition, therapists need to be able to engage and
work with young people of a variety of ages, developmental levels and backgrounds, as
well as parents and carers, in a culturally competent manner. They also need to have
knowledge of psychopharmacology as it relates to young people. The generic compe-
tencies relate to knowledge of specific models of intervention and practice, an ability
2 The Handbook of Counselling Children & Young People

to work with emotions, endings and service transitions, an ability to work with groups
and measurement instruments and to be able to use supervision effectively. The ability
to conduct a collaborative assessment and a risk assessment is paramount. Crucially,
BACP (2014) suggest the therapist needs to be able to foster and maintain a relation-
ship which builds a therapeutic alliance and understands the client's ‘world view. In our
experience most proficient therapists, irrespective of their modality, work to achieve
this trusting relationship necessary for human change. BACP are also developing a
children and young people specialist training curriculum based on the competences.
It is intended that this will be a post-graduate top-up for counsellors/psychotherapists
who have a completed an ‘adult’ practitioner training and who want to develop knowl-
edge and skills to work with children and young people.
This book dovetails smoothly with these developments. We use the term ‘therapeutic
work’ as an overarching term for the range of therapies referred to loosely as ‘counsel-
ling’ or ‘psychotherapy. Although each professional body has their own definition of
counselling and psychotherapy, they are all similar in nature. ‘Counselling and psycho-
therapy are umbrella terms that cover a range of talking therapies. They are delivered
by trained practitioners who work with people over a short or long term to help them
bring about effective change or enhance their wellbeing’ (BACP, www.bacp.co.uk/).
However, we would like to add to this definition, which refers to ‘talking therapies; to
include creative forms of communication including artwork and play to address the
therapeutic needs of the wide age range of children and young people covered in this
book (3-18 years and beyond, for young people with developmental delays).
This handbook is unique as the only comprehensive resource for counsellors, train-
ees and trainers working in the field of counselling children and young people that is
linked to high quality online resources developed by BACP. The book is designed to
provide essential reading for all counselling trainees and a guide to curriculum for the
trainers. Any counsellor working with children and young people, or aspiring to work
with this client group, will be able to refer to the handbook and use it to contribute
to their continuing professional development. There are challenges around improv-
ing the quality and provision of support for the mental health of children and young
people. Statistics show that the suicide rate is rising and children and young people’s
levels of well-being are falling. The quality of counsellor training and the evidence base
required to ensure effective provision are both issues addressed in this book. Each
chapter provides references to research and the evidence base, further supplemented
through links to the BACP/NHS MindEd e-learning resources, which are indicated at
the end of each chapter, where appropriate. By far the most important aspects of this
book are the unique contributions each author has made. Each is expert in their field
and has their own approach to the chapter topics, which makes for overlap in places,
but with a different perspective in each case. The handbook will invite you in as reader,
hold your attention and entice you to read further, giving you flavours of approaches to
 Editors’ Introduction

counselling children and young people that may be new to you and insights into topics
that stimulate and leave you wanting more.
We intend this handbook to provide a comprehensive guide to the complex field of
counselling children and young people in the UK and as a resource in the international
arena. As its intended audience, you may be a trainee, trainer, practitioner, a service
provider or a commissioner of therapeutic work with children and young people. The
level of your training programme may be introductory or more advanced. The book
is based on a set of values and principles, the rights of the child, the need to keep the
child at the centre of our therapeutic work, unconditional acceptance, trustworthiness
and congruence. The book will help you as the reader to identify, clarify, reflect upon
and work with the underpinning legislation, ethics and values; theoretical approaches;
research evidence; interventions and techniques that apply to the practice of counsel-
ling children and young people. You will be introduced to the diversity of working with
children and young people at different developmental stages. In order to achieve this,
the handbook follows a structured and logical approach that introduces you to a set
of underpinning values related to legislation, policy and professional practice, dem-
onstrating how these are used in practice by providing you with case study material.
Although each case study represents the therapeutic way of working, the actual cases
are amalgams in order to protect client confidentiality and identity. The handbook is
presented in four major parts with 28 chapters. Throughout the book there is evidence
of how therapeutic work with children and young people and the related services have
developed historically. Although a range of theoretical approaches and different ways of
working are explored in this book, the philosophical base when translated into under-
pinning values and principles of working with children and young people includes
trustworthiness of the counsellor, acceptance, empowerment and a belief in the power
of relationship. These values and principles will be woven throughout the book and
are present in every chapter to enable theory, research and practice to be linked and
consolidated for you, the reader.
As the field of counselling children and young people has rapidly developed over the
past few years, the delivery, approaches to counselling and the nature of interventions
have increased in number and range and been applied across an increasing range of
contexts. Counselling practitioners come from a variety of backgrounds and professions.
They bring new ideas into the field and also adapt concepts, ideas and tools developed in
their own professions, including theoretical approaches. The diversity of the field cre-
ates increasing opportunities for interdisciplinary work and cross-fertilisation of ideas.
However, there is also a sense of counsellors requiring help to position themselves pro-
fessionally in relation to theoretical approach, methods, techniques and tools, bearing in
mind the increasing demand for practice based on research evidence.
Questions that you may ask as a counselling practitioner, trainer, trainee or com-
missioner of therapeutic work with children and young people may include: Which
4 The Handbook of Counselling Children & Young People

is the best counselling approach for working with young children in primary schools?
How is a therapeutic relationship with an adolescent who has problem behaviour estab-
lished and maintained? Is it possible to provide complete confidentiality for a child in
therapy? Should a child be ‘sent’ for counselling? Is parental permission needed to offer
counselling to an adolescent? Although not all of your questions will be answered, this
book provides the answers to a range of questions that the authors have been asked over
their many years of experience.
The structure of the book has been designed to enable you to access any section
independently of the others, yet they intrinsically link together. The book comprises
four overarching sections: Theory and Practice Approaches; Counselling Practices and
Proceses; Practice Issues; and Practice Settings.
In ‘Theory and Practice Approaches, the authors discuss a range of therapeutic
approaches aimed at helping children and young people at different ages and stages.
This includes child development and attachment; the child-centred approach, psy-
chodynamic, cognitive-behavioural, gestalt, transactional analysis, play therapy and
other creative therapeutic approaches. Where appropriate, the chapters will look at
brief therapy where it is included within each approach. Age-appropriate interven-
tions in relation to each theoretical approach are examined, for example, brief therapy,
play therapy and its theoretical perspectives; cognitive-behavioural approaches such
as problem-solving, and solution focused therapy. Each chapter refers to the underly-
ing principles fundamental to counselling work with children and young people and
relevant research. ‘Counselling Practices and Proceses’ examines the nature of the
process that can take place when counselling children and young people and looks at
referral and indications for therapy, including assessment; preparation for therapy and
beginnings; the therapeutic alliance and the middle part of therapy; counselling skills;
supervision; group work and endings. The section incorporating ‘Practice Issues’ looks
at law and policy; ethics; diversity; bereavement; depression; suicide and self-harm;
sexual abuse; and eating disorders. ‘Practice Settings’ identifies and examines working
in a range of contexts, statutory health and social care services; non-statutory services,
for example, the third sector. The chapters in each major part of the handbook have an
established common structure, and all case material used in the book is anonymised,
to preserve confidentiality. This is the structure, which organises information and acts
as a guide for you, the reader. Each chapter includes a set of questions designed for
your further reflection on the topic with suggestions for reading that will allow you
to investigate topics in more depth. Therefore, it is hoped that after engaging with the
informative review of each key topic you will not only have a good understanding of it
but will be interested in investigating the topic further.
 Part |

Theory and Practice

Approaches
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 Child Development and
Attachment
Simon Gibbs, Wilma Barrow and Richard
Parker

This chapter includes:

e Developmental theory
e The role of the primary caregiver in supporting development
e Attachment
e Implications for counselling

introduction

In this chapter we outline some theories about children’s development, and the role of
the primary caregiver (and other adults) in supporting children’s development.
We then summarise the development of attachment theory and outline findings in
relation to the theory as proposed by Bowlby (2005). In so doing we recall that the
origins of attachment theory lie in cognitive psychology. We also note the role of
two behaviours relating to the development of attachment: exploratory behaviours
associated with cognitive, social and communicational development; and caregiving
associated with parental availability, responsiveness and intervention. These are, as we
discuss later, also crucial characteristics of therapists.
8 The Handbook of Counselling Children & Young People

Regarding exploratory behaviours, we acknowledge the importance of the work

of theorists and researchers such as Vygotsky, Bruner and Wood (see Wood, 1998)
in describing how parents scaffolding their child’s play facilitate exploration and the
development of physical, social and communicational skills. Discussing this, we note
the dialogic nature of these interactions (Gratier and Trevarthen, 2007). Thus, accord-
ing to attachment theory, with appropriate contingent parental interaction, the child
will develop a representation of herself as able to help herself and as worthy of receiving
help when necessary (Bowlby, 1977a; Thompson, 2000).
Before considering these theories in detail we offer a brief introduction to issues aris-
ing from child development studies. Child development psychology is complex, and
as ideas about childhood and children have shifted, the emphasis on development in
childhood has itself been criticised. The notion of the child as the ‘unfinished’ version
of the adult has been questioned and attention has shifted to development across the
life course (Spiel, 2009).

Child Development: A Critical Overview

Developmental psychology has, over time, included a range of theoretical positions.

Historically, these have differed regarding the emphasis placed upon physical, psycho-
logical and social factors implicated in the process of development. Historically, too,
emphasis has been on studying the child objectively with minimal attention to the child’s
subjective experience (Hogan, 2005). Current thinking tends to reflect the dynamic
relationship between factors implicated in children’s development. Development may
be seen as a dynamic process of interactions between innate biological (the cortex,
for instance) and psychological factors (such as temperament), and influences such as
caregiver responsiveness (Sameroff, 2009). Such complexity and reflexivity is reflected
in newer theoretical positions such as neuroconstructivism. While emphasising the
importance of neural structures for our understanding of cognition, neuroconstruc-
tivists argue that the developmental trajectory results from interactions between
biological and environmental factors that shape and constrain emerging neural struc-
tures (Westerman et al., 2010).
While development can, therefore, be understood as a process of dynamic transac-
tion between multiple factors, a number of other findings have emerged from recent
research in developmental psychology. We identify those that we consider of particular
relevance for those therapeutically involved in work with children who have experi-
enced difficulty or trauma in their lives. It is important to emphasise links between
these findings and associated philosophical and methodological debates. The findings
include the following:
 Child Development and Attachment 9

e The role of experience in neurodevelopmental plasticity (Goswami, 2004;

Van \jzendoorn
and Juffer, 2006). Although research suggests certain experiences can lead to long-term
difficulty, the possibility of catch-up is recognised.
e The primary need for significant relationships (Braten, 1998; Linell, 2007; Trevarthen,
2001). Early developmental theorists like Freud considered relationship to be a means
of
satisfying basic biological need. Increasingly the importance of relationship as a primary
need has been recognised in research demonstrating the role of intersubjectivity and
the attunement ofthe young infant to the other (Meltzoff and Moore, 1998; Newson and
Newson, 1975; Trevarthen and Aitken, 2001). Research on motivation led Deci and Ryan
(2000), for instance, to conclude that relatedness is fundamental to human psychological
well-being.
e Understanding the environment within which the child develops as a complex eco-
system. Bronfenbrenner (1979) theorised that children develop within nested systems.
Microsystems include the people and organisations within which the child has most
immediate contact, such as family, peer group or school class. The mesosystem refers
to the interface between aspects of the microsystem such as the interactions between
a child's parents and teachers. The exosystem involves the wider community and the
systems which directly or indirectly affect the child such as parental workplace or local
neighbourhood. Finally, the macrosystem involves culture, ideology and legal systems.
The relationships between these systems are transactional, as is that of the child and the
various systems.
e Linked to ecosystemic understanding is the need to recognise cultural diversity (Dasen
and Mishra, 2000; Kagitcibasi, 1996). Developmental psychology has been criticised for
relying on European and American-based research, and there have been calls for a more
inclusive approach to the discipline (Marfo et al., 2011). This is of particular importance
given this book’s purpose. Research looking at children’s emotional reactions suggests
differences between cultural groups’ responses to difficult situations (Cole et al., 2002).
While it seems to be the case that all children develop attachment behaviours, there is
evidence (Gonci et al., 2012) that the meaning and salience of these behaviours may be
culturally specific, and have implications for counsellors and therapists. There is debate
about how psychologists respond to cultural diversity. On one side of the philosophical
and methodological divide is the cross-cultural comparative or etic approach. On the
other lies cultural-psychology or emic approaches (Dasen and Mishra, 2000). The Turkish
developmental psychologist Kagitcibasi (1996), for example, has taken a mediating
position due to concerns that uncritical approaches to cultural relativism might lead to
failure to intervene in the lives of children whose development is being compromised
by adversity. She has suggested a synthesis of etic and emic approaches to inform the
development of contextually sensitive interventions (Kagitcibasi, 1996). This requires
collaboration with those positioned within cultures and avoiding culturally imperialistic
interventions. Spiel (2009) identified Kagitcibasi’s work as an example of how discussion
may be re-focused on positive cross-cultural development.
10 The Handbook of Counselling Children & Young People

e The development of strength-based theories of development (Lerner et al., 2005). This is

based on the ideas of neuroplasticity noted above. Lerner et al. have studied the develop-
ment of competence, confidence, connection, character and caring through appropriate
programmes of activity and social policy. Their focus is upon the contextual appropriate-
ness of interventions, with sensitivity to cultural diversity.

It is also important to recognise that the development of young people is an emotive

topic. The factors contributing to ‘good’ and ‘bad’ outcomes for children and the implica-
tions of these outcomes for wider society are fiercely debated within the media — as was
evident during the aftermath of the UK 2011 riots (Channel4News, 2011). Ideologically-
driven sound bites often reflect notions of development based on outdated, linear
models of causality. Contemporary theories of child development can help by counter-
ing and reframing these. This is also important to those involved in therapeutic work
who attempt to support the well-being and attunement of children, young people and
their families.
Following this broad introduction to the field of child development we now turn to
specific theories and consider their role in explaining cognitive and social-emotional
development.

Theories of Children’s Cognitive Development

We see daily the range and diversity of evidence of how children and young people
develop physically, psychologically and socially. We may also see a range of parental
behaviours toward children. These range from appearing to embrace warmth of care
and support, to those seeming to engender anxiety, wariness, frustration or hostility.
Thus we may witness how we consciously (or less consciously) shape the way babies are
handled, how children learn from adults and each other, and how culturally we manage
the processes of development into adulthood.
Some of the mechanisms that support children and young people’s development
are undoubtedly biological and genetic (Fonagy and Target, 2002; Schore and Schore,
2008) and the importance of these for the understanding of attachment is becoming
clearer (see, for instance, Galbally et al., 2011). Although we do not underestimate the
salience of the biological and physical factors that affect development, we will not deal
with these extensively here. The present context demands attention to the sociocultural
factors shaping the way we interrelate and interact with children’s development.
We have already indicated that the history of developmental psychology involves a
range of theoretical perspectives that reflect differing emphases. These have ranged
across varying paradigms. In the early 20th century much research was associated with
the psychoanalytical work of Freud and his followers (most notably his daughter Anna
 Child Development and Attachment 11

and Melanie Klein). Their work was an attempt to understand the impact
of underlying
instinctual, emotional and intra-psychic factors on children’s development. One
of Klein’s
insights was in recognising that children’s play was a means to communicate
feelings
and instincts that, at an early age, children were otherwise unable to communi
cate. Of
significance for later in this chapter, when we consider attachment theory in detail, is
Anna Freud's belief that, in the psychoanalysis of children, the analyst represents and
takes on aspects of the role of a parent (Freud, 1946; Keinanen, 1997):
However, in a deliberate reaction to the subjective, intra-personal nature of the psy-
choanalytical perspective, the work of psychologists such as Watson and Skinner was
devoted to the development of psychology as an objective science. In that paradigm
studies were carried out to establish how children’s behaviour might be ‘conditioned’
or moulded - as had been evidenced in animal studies. Skinner proposed that chil-
drens learning would be significantly enhanced through the application of appropriate
reinforcements (Skinner, 1968). Thus, specific behaviours (for example reading words
correctly) may be reinforced by a smile from the parent. These ideas were adapted by
Bandura to form the basis of his social learning theory (Bandura, 1977). In Bandura’s
view children learn by observing and imitating behaviours which, if appropriate, are
then reinforced by significant others. On the basis of this feedback, children develop a
belief in their ‘self-efficacy (Bandura, 2001).
Such theories have helped inform work with children. However, they have been
criticised for their objectification of children. They have also been regarded as both
underplaying children’s own agency and contribution to their development, as well as
ignoring how exploring their environments enables children to construct knowledge
and understanding (Gillman et al., 1997; Hogan, 2005; Radin, 1991).
Our understanding of children’s cognitive development has been greatly influenced by
the work of Piaget and of Vygotsky. While their work has been of significance in its own
right, we also suggest it is important to consider these (and other) theories here, since
the way children’s thinking develops and how adults understand that process of devel-
opment play a major part in shaping the relationships between carers and children. It is,
however, important to recognise that while Piaget's work provided illumination of the
development of children’s cognition through a series of stages, this story is incomplete.
Children develop through interaction with their biological selves and the physical,
social and cultural world (Wood, 1998). Understanding of this came from Vygotsky
(1962), whose work demonstrated how adults in communicating aspects of the cultural
context influenced the development of children’s thinking.
Piaget’s work is still important for its insights into children’s perceptions and how we
may conceptualise children’s development. It has little to say, however, about how or
why children develop as they do. Piaget (1953) charted the development of children’s
thinking as a series of stages. In the earliest stage (from birth to two years), in which
children use their senses and motor abilities, Piaget held that children explore reflexively
12 The Handbook of Counselling Children & Young People

and do not consciously ‘think’. However, they do show different reactions in dif-
fering situations — for example ‘stilling’ when the caregiver approaches; beginning to
show they ‘understand’ that although out of sight, objects still exist - though challenge
is emerging (see Kagan, 2008). It is in the next ‘preoperational’ stage (from around two
to seven years of age) that children start to form mental representations and label these
using words. During this stage they start to show they can see things from another's
perspective and distinguish between animate and inanimate objects. As they progress,
their ability to think logically and to formulate abstract thoughts develops. Piaget found
that between seven and 11, children began to realise the logical nature of operations
and classifications. More recent research, however, has suggested that these abilities do
not necessarily emerge spontaneously but arise in association with certain cultural and
contextual factors (see Donaldson, 1978; Maynard and Greenfield, 2003). Through cre-
ative adaptations to Piaget’s methods and attention to how tasks were communicated,
Donaldson, for instance, was able to demonstrate young children’s ability to perform
cognitive tasks earlier than predicted by Piaget, so long as the context was meaningful.
Such work showed that the way tasks were constructed and communicated could be
critical in determining children’s success or failure. Cross-cultural research has rein-
forced the importance of this by demonstrating that rates of cognitive development
can vary across cultures, dependent on cultural and environmental factors (Dasen and
Mishra, 2000). While Piaget's work provided a framework for viewing the develop-
ment of children’s cognitive abilities and provided the concept of ‘readiness, the work
of Vygotsky has enabled greater understanding of the tools (including language and
cultural heritage) that mediate development.
Vygotsky (1962) differed significantly from Piaget in his concepts and methods by
showing the importance of communication as a crucial factor and providing clues
about how children progress in their development. Thus, Vygotsky considered that
when talking to themselves (in their ‘self-talk’) children used language as a tool to
help them overcome problems (Vygotsky, 1978; Winsler et al., 2006). In the ‘zone of
proximal development’ (Vygotsky’s term), while a child may be unable to succeed with
a task or problem on their own, with the help of someone more expert (a child or
adult), the child could be more successful. Vygotsky suggested that when acting on her
own, the child may be heard commentating on her activity, expressing both curiosity
and puzzlement - essentially to herself. With her parent it was possible to see how
the child's self-talk became a dialogue with a more expert other. This other, if suffi-
ciently skilful, could help ‘scaffold’ the child’s problem-solving of a task confronting her
(Keen, 2011; Wood et al., 1976). Through such skilful (spontaneous and contingent)
verbal and non-verbal intervention, the parent, in dialogue with her young child, also
facilitates the development of intersubjectivity and synchrony (Newson and Newson,
1975; Trevarthen, 2011). Through such processes adults help regulate children’s active
and purposeful exploratory engagement with their surroundings (David et al., 2012;
 Child Development and Attachment 13

Sroufe, 2005). With the reassurance and guidance of such ‘scaffolding’ the child may
feel safer in exploring and, almost literally, extending their grasp to take on new chal-
lenges. Thus, the child’s exploratory play can be seen to be reciprocated by their carer’s
behaviour. It is with this theoretical basis that we now turn to a consideration of the
role of ‘attachment.

Attachment Theory

Attachment theory describes and predicts the dynamic effects of long-term relation-
ships between humans. Most especially the theory deals with the relationship between
the ‘primary caregiver’ and child from birth through childhood. The theory provides a
means of understanding the way that we form strong emotional bonds with particular
others and the distress that may ensue when these bonds are disrupted.
In developing the theory of attachment, Bowlby (1977a, 1977b) was heavily influ-
enced by two quite disparate sets of observations: first, the work of clinicians who, in
the 1930s and 1940s, had observed the consequences for children of institutionalisation
and disruption of stable parenting; second, the ethological studies of Konrad Lorenz
(Ainsworth and Bowlby, 1991; Lorenz, 2002). Lorenz had noticed the instinctual
behaviour, imprinting, that emerged spontaneously in many animal species between
mother and offspring. Counter to prevailing theory, this appeared unrelated to feeding
(Lorenz, 2002).
Although acknowledging inheritance from psychoanalytic and behavioural theories,
Bowlby (1977a) was at pains to differentiate the instinctual nature of the attach-
ment bond from the drives and reinforcements postulated by those other theories.
Attachment behaviour was conceived as

... any form of behaviour that results in a person attaining or retaining proximity to
some other differentiated individual, who is usually conceived as stronger/wiser. While
especially evident during early childhood, attachment theory is held to characterise
human beings from the cradle to the grave. (Bowlby, 1977a: 203)

However, in combining ideas from psychoanalytic, cognitive, biological and ethologi-

cal approaches, Bowlby provided a clearly delineated conceptual framework (Bowlby,
1977a) for testable hypotheses in relation to children’s development and mental health.
This has led to many detailed studies confirming significant relationships between
attachment and, for instance, the development of children’s behaviour (Fearon et al.,
2010), or later anxiety disorders (Esbjorn et al., 2012). However, it is important, as
Thompson (2008) cautioned, to avoid taking a view that ‘attachment’ can account for
all aspects of later development. It is clear, as Fonagy and Target (2002: 328) stated:
14 The Handbook of Counselling Children & Young People

Attachment relationships are formative because they facilitate the development of the
brain’s major self-regulatory mechanisms, which ... allow the individual to perform effec-
tively in society [but] they offer no guarantee the individual will achieve this, and they can
place powerful limits on the individual's chances of coping with major adversity.

We also note a high probability that adverse circumstances, such as poor socioeco-
nomic conditions, may prove the foundation for a circularity of perpetuating, if not
deteriorating, patterns of poor attachment and adult mental health problems (Stansfeld
et al., 2008). It is thus important to understand how patterns of attachment are estab-
lished and what may be done to enhance these proactively, or at least therapeutically.
The infant’s attachment bond starts to form at birth (Zeanah et al., 2011), if not
earlier (Rackett and Holmes, 2010; Walsh, 2010). The young child develops selec-
tive attachments with a small number of adults who are most closely involved in her
care (Rutter, 1995). The key caregivers have a critical, responsive, role throughout
the first year to 18 months of the child’s life (Fonagy and Target, 2002; Thompson,
2000). As we noted above, this is effected through the ongoing processes of contingent
and synchronous dialogue between caregiver and baby (Bowlby, 1977a; Fonagy and
Target, 2002; Newson and Newson, 1975). The provision of early and sensitive
care by key caregivers is one factor in supporting secure attachment (that serves to
control distress and facilitate the development of neural self-regulatory mechanisms).
This helps provide foundations in adulthood of secure relationships and social behav-
iour (Crespi, 2011; Fonagy and Target, 2002; Johnson et al., 2010), though this has
been disputed by Rutter et al. (2009). However, it is also evident that levels of caregiver
affect are in a reciprocal relationship with children’s own emotional security (Murray
et al., 1999). In less fortunate circumstances, if the crucial caregiver role is not fulfilled,
the child may not develop a sense of security and confidence in exploration and sociali-
sation. There is evidence to indicate that inconsistent care in infancy may be predictive
of certain outcomes in adulthood. It has been suggested that resultant attachment styles
can be conceptualised on two dimensions: attachment-related anxiety and avoidance
(Mikulincer et al., 2013). The first relates to doubts about self-worth and that oth-
ers will not provide support when needed; attachment-related avoidance, in contrast,
relates to distrust of others’ motives and goodwill, causing behavioural and emotional
detachment. Those who are either highly anxious or avoidant - or both - may ‘suffer
from attachment insecurities, self-related worries, and distrust of others’ goodwill and
responsiveness in times of need’ (Mikulincer et al., 2013: 607). However, according
to Bowlby (2005), attachment behaviours, such as seeking support, may be evident
throughout life (see also Ainsworth, 1989). Bowlby (2005) also maintained it is possible
to experience relationships later in life that provide a sense of secure attachment. (As
we discuss below, this may be seen as an integral component of therapeutic relation-
ships.) There is also some encouraging evidence that intervention in schools and early
 Child Development and Attachment 15

years settings may help counteract initially unfavourable factors (Kennedy et al., 2010;
MacKay et al., 2010; Roggman et al., 2009).
Despite the importance of attachment to the development of the young child it is
important to emphasise, however, that attachment does not provide a comprehensive
explanation for all social relationships and behaviour, and that other factors need to be
considered (Rutter et al., 2009).

Discussion and Synthesis: The Implications for Counselling

As we have shown, children’s development may be conceptualised and studied within

a range of paradigms. We now bring these ideas together to provide a possible founda-
tion for professional work with parents and their children.
It is evident that children’s development and long-term well-being are the product
of genetic, biological and environmental (including parental) factors. Therapeutic
involvement is unlikely to be sought before a child is born. It is more likely to revolve
around the relationship formed with parents and the relationship they have with their
children. Within that nexus, the first and most crucial relationship is that between
caregiver and infant. The security of well-formed attachment, and the implicit contin-
gent regulation of emotions and exploratory play that should be found, forms the basis
for the child’s social, cognitive and communicational development (Meins and Russell,
1997; Thompson, 2000; Trevarthen and Aitken, 2001). It is within the unconscious,
instinctual dialogue between caregiver and baby that begins at birth and develops and
changes over time that the infant develops. This relationship provides a safe environ-
ment in which the infant can develop the confidence to explore, and the caregiver can
develop the confidence to provide care and support. In turn, that reciprocal, attuned,
relationship forms the basis of further development from which emerges the child’s
increasing physical and oral communication (Bowlby, 1977a, 2005; Vygotsky, 1962).
Gradually and contingently, the child’s oral utterances and physical gestures are guided,
reinforced and commented on by the caregiver (Keen, 2011; Wood et al., 1976).
Just as the child has to explore to develop and the primary caregiver has to be ‘avail-
able and responsive as and when wanted, [and be able] to intervene judiciously should
the child or older person who is being cared for be heading for trouble’ (Bowlby, 1977a:
204), so does the therapist need to provide attuned interaction with her client (Bowlby,
2005: 159; Mallinckrodt, 2010; Mikulincer et al., 2013). As Bowlby (2005: 172) also
maintained, “The therapist strives to be reliable, attentive, empathic and sympatheti-
cally responsive to his patient’s exploration, and also to encourage his patient to explore
the world of his thoughts, feelings and actions. These are qualities to be found in the
counselling relationship, however brief.
16 The Handbook of Counselling Children & Young People

It is also worth considering the relationships children have with significant others
such as grandparents and siblings, as these may offer support through periods of transi-
tion or trauma (Lussier et al., 2002). Furthermore, Dunn (2004) summarised evidence
that relationships with peers can provide support through transition. Dunn considered
that relationships with parents can affect peer relationships but importantly also demon-
strated that relationships with peers can influence a child’s relationship with her parents.
It is therefore important to assess the quality of the child’s relational network in consid-
ering any form of intervention. There is evidence that some difficulties require work to
be conducted with the child or young person and their family (Fonagy et al., 2002).
Therapeutic endeavours are not without risk. For example, some who seek counselling
will also be seeking security and attachment. If, as may happen, the client experiences yet
another failure to form a secure attachment (perhaps because the therapeutic sessions
are prematurely curtailed), she may place even less trust in any other relationship —
personal or therapeutic. This may be particularly problematic in direct therapeutic
work with children and young people (Allen, 2011). For children who show clear signs
of insecure or disordered attachment it is, therefore, considered more appropriate to
work with the primary carer first, before then working with the carer and young person
together (Allen, 2011).

Conclusion

In this chapter we have given an overview of current notions about children’s develop-
ment and the development of attachment bonds. In our synthesis of these ideas we have
considered what these ideas might imply for those, such as school counsellors, who
engage in therapeutic work with children and young people.
The findings from research are informative. In relation to the formation of attach-
ment bonds, most salient is the evidence from developmental psychology that has
given insight into the importance of contingency, availability, synchrony and dialogue.
In the absence of at least some of these features in an infant’s development, attachment
bonds may be impaired. Likewise, the presence of parental warmth, care and support
that enable the child to explore and learn is critical for development.
Therefore, rather than predicate the purpose of this chapter as a foundation for ther-
apeutic intervention, it would be better, we think, to be pre-emptive. Thus, as Fonagy
and Target (2002: 328) have said:

The target for early intervention becomes clear: no child should be deprived, through
lack of adequate support in his earliest relationships, of the opportunity to develop his
interpersonal, interpretative capacity to a level that will enable him to tackle the adver-
sities that life is likely to bring him.
 Child Development and Attachment 17

However, in the same vein we can conclude that understanding that children and young
people's development is facilitated by appropriate care and attachments is important for
those responsible for the provision of help for anyone whose early life was adversely
affected.

=\
Case Study Lise
Lise’s mother, Sara, 23, is a single parent. Lise is six and her only child. It seems Sara never speaks
about Lise’s father. In school Lise is said to be quiet and withdrawn. Her class teacher is con-
cerned because she appears rather isolated from her peers and sometimes wets herself. Her
attainments in school are said to be well below the average of her class. Her drawings of people,
for instance, are very simple; her understanding and use of language is said to be more like a
much younger child.

Summary

In this chapter we examined:

e Current notions on children and young people's development

e Development of attachment bonds and primary carers
e Asynthesis of the above ideas and how they are relevant to counsellors
e Findings from research

Reflective Questions

1. In your work do you notice children or young people forming an ‘attachment’ with you? If
so, what do you notice and how do you respond?
2. In considering work with children or young people, how important is it for you to also
explore the relationship their parents or carers might have with you?
3. Which of the theories about children’s cognitive development have greatest resonance for
you in your practice? What do you see as the theory's strengths and how do you see the
theory at play in your work?
4. What parental behaviours might you seek to encourage and how?
5. What do you find most helpful when engaging in work with adolescents and how might the
ideas in this chapter influence your future practice?
18 The Handbook of Counselling Children & Young People

There are no specific answers to the questions - you are asked to reflect and use your
own experiences.

ee ne ee ee ee ee ne ee eee Sr aeteraenn
¢
i Learning Activities
i
I Read the case study: Lise. The school would like your help.
i
i 1. What hypotheses do you already have?
|
i o What is the basis of these?
i © In these, can you differentiate between the effects of factors that might relate to
i ‘development’
and those that might relate to ‘attachment bonds’ and, if so, how?
i
2. What other information would you like to have?
i
| o How would that affect your hypothesising?
i
3. In relation to the case details (above), who else would you like to meet, and why?
i
| 4. What rationale can you provide for what you might do next?
6 x

Further Reading

Bowlby, J. (2005) A Secure Base: Clinical Applications of Attachment Theory. London: Routledge.
Sameroff, A. (2009) The Transactional Model of Development: How Children and Contexts Shape Each
Other. Washington, DC: American Psychological Association. pp. 3-21.
Vygotsky, L.S. (1962) Thought and Language. Cambridge, MA: MIT Press.
Wood, D. (1998) How Children Think and Learn. 2nd edn. Oxford: Blackwell.

Online Resources

The MindEd e-learning resource CM 5: Developmental Themes in Children and Young People could
be useful, especially: CM 5.1 —- Becoming Independent; CM 5.2 - Developing Relationships; CM
5.3 - Developing Sexuality.
Counselling MindEd: http://counsellingminded.com.
 Child and Young
Person-Centred Approach
Graham Bright

This chapter includes:

e The origins and key tenets of the person-centred approach (PCA)

e Rogers’ core conditions
e Person-centred practice with children and young people

History and Background

The person-centred approach (PCA) to therapy is grounded in Carl Rogers’ formative work
with children and young people; it seems right, therefore, as a means of introduction to
this chapter, to recover some of that history here. Carl Rogers (1902-87) was born near
Chicago. His family moved to live and work on a farm when he was in high school. Rogers
was by all accounts a studious but shy boy who did not have many friends outside the family
circle. Growing up, he had a keen interest in science, and his formative years were signifi-
cantly influenced by his family’s Christian beliefs. Rogers studied agriculture at college for
two years before briefly exploring a vocation to Christian ministry. During this period
he attended the International World Student Federation Conference in Beijing, which he
described as ‘a most important experience for me’ (Kirschenbaum and Henderson, 1989: 9).
Here Rogers observed a good deal of disagreement and even animosity amongst delegates,
20 The Handbook of Counselling Children & Young People

which led him to conclude that pluralistic divergence was phenomenologically inevitable.
As a result, he began to question some of the more affixed doctrine that he had grown up
with (Barrett-Lennard, 2013). The result — to his parents’ despair - was that the newly-
married Rogers chose to attend a highly liberal seminary, where he was exposed to heuristic
forms of inquiry which enabled Rogers and his fellow students to reach their own very
personal conclusions regarding matters of faith and experience.
These student-led seminars helped Rogers to clarify his own beliefs; as a result, he felt
it incongruous to continue pursuit of the ministry to which he could no longer profess.
It was at this time that Rogers felt drawn to the field of child guidance, an arena which at
that time was saturated by Freudian thinking. He was appointed to a team of three psy-
chologists working with the Society for the Prevention of Cruelty to Children in Rochester,
New York. Rogers recounted his time at Rochester in the psychoanalytical diagnosis and
treatment of young people as being a period of deep learning, yet one which left him re-
evaluating the prescriptive nature of psychoanalytical diagnostic formation and treatment.
One particular incident with a mother of a challenging young boy proved to be seminal.
Rogers recalled trying (without success) to offer psychoanalytical interpretation regarding
the underlying nature of the family’s symptomatic behaviours; later, however, the mother
began to detail her own distress regarding her marriage. Rogers cited this incident as:

one of anumber which helped me to experience the fact — only fully realized later - that
it is the client who knows what hurts, what directions to go, what problems are crucial,
what experiences have been deeply buried. It began to occur to me that unless | hada
need to demonstrate my own cleverness and learning, | would do better to rely upon
the client for the direction of movement in the process. (Kirschenbaum and Henderson,
1989: 13; emphasis in original)

Rogers’ first book, The Clinical Treatment of the Problem Child, was published in 1939
and viewed as a welcome contribution to an emergent field. In it kernels of what we
have come to understand today as the PCA can be seen. Relational qualities between
practitioner and ‘patient’ are described and accentuated, most notably that of non-
judgemental acceptance. Here too we see the emergence of Rogers’ ideas on the
‘actualising tendency. Barrett-Lennard (2013: 35) notes that ‘by the time his first book
was completed, what was to become non-directive client-centred therapy was germi-
nating strongly in the thought and practice of its founder’

Theoretical Underpinning

Over the ensuing years, Rogers refined his theory, arguing that the quality of rela-
tionship between therapist and client was central to facilitative growth and change.
 Child and Young Person-Centred Approach 21

In Rogers’ view it is unnecessary to engage in therapeutic formulation drawn from

the client's past; rather, he emphasised the import of empathically experiencing with
the client the subjective, transcendent essence of their here-and-now reality as it is
fluidly experienced. In this way, Rogers’ work related to Husserl and Heidegger's ideas
of phenomenological construction (Cooper and Bohart, 2013) and posited a distinct
shift from directive forms of therapy which draw upon therapist interpretation and
expertise towards non-directive, facilitative work in which the client - motivated by
their actualising tendency - instinctively ‘understands at different levels of their being
what is needed for their own healing and growth (Rogers, 1959). Here the therapist
seeks to enter and understand the Other’s subjective reality as they experience it, and to
offer particular conditions which enable the fluidity of the Other’s experience of being
and becoming as determined by their congruent response to what is happening within
their field of reality (or environment) to be realised. What Rogers emphasised, there-
fore, is a ‘way of being’ with another which enables that Other to intrinsically nurture
their own organismic processes without recourse to technicised therapeutic interven-
tions which draw upon more prescribed theoretical formulations (Merry, 2008; Rogers,
1951). The PCA has oft been criticised for a lack of theoretical rigour and therapeutic
wizardry associated with other psychotherapeutic approaches; yet proponents would
argue that it is theoretically rich and necessitates advanced levels of practitioner dis-
cipline, integration and growth - it requires, perhaps more than any other approach,
that therapists bring and use their whole being to assist the client on their therapeutic
odyssey (Mearns and Thorne, 2013).
Rogers’ work itself was based on certain theoretical underpinnings which he
described throughout his career as particular hypotheses. This ongoing experiential
work led Rogers to develop and iterate his own theory of the person. Central to his pos-
tulation was that each human being has an ‘actualising tendency, which Gillon (2007:
27) describes as:

an inherent, biological tendency towards growth and development. This tendency is

located at the level of the organism as a whole and is seen as the single, basic motiva-
tional force driving each human being toward the fulfilment of their unique potential.

The Rogerian vision of the person is positive and hopeful. It views with optimism the
possibilities of human potential (Reeves, 2013), observing the self as changing and
dynamic, and as responsive to different stimulae within its environment. This fluid-
ity, however, is underpinned by particular characteristics which might be viewed as
relatively consistent at given moments of time and more generally across the lifecourse
(Merry, 2008). For the infant, there is no experiential division between what they per-
ceive as internal and external to the self (Cooper et al., 2013). As they grow, babies
become aware through reflective interactions with others of their separateness, result-
ing in experiential differentiation. Infants begin to recognise the T or ‘me’ or ‘self’ as
22 The Handbook of Counselling Children & Young People

being separate from others, from which a concept of the self begins to emerge (Gillon,
2007). The self requires two principal needs to be met in order to develop higher actu-
alised outcomes. We can, according to Merry (2008), consider these as needing positive
regard from self (internal regard) and others (external regard). External regard tends to
manifest itself as we grow and develop through our need of acceptance, praise and rec-
ognition from those close to us, including parents, other caregivers, and those whom
we admire in some way. At the same time, each individual needs to develop trust in
their own intrinsic organismic processes in order that a diversity of needs are met in
nourishing the potential of the actualising tendency, which Gillon (2007: 28) describes
as ‘an on-going, biologically-driven valuing process which allows each of us to assess
experiences that are enhancing to, or maintaining for, our organismic needs and poten-
tialities. Such is our need, however, for others’ approval that over time we adapt our
intuitive feelings and behaviours and conform to meet others’ expectations to the det-
riment of our organismic needs and processes. We become subtly, and sometimes not
so subtly, subjected to and imprisoned by particular messages which become imbibed
deep within us: messages of conditionality - ‘I will accept you if you conceal this or
“change” that ... I will love you if ... I like this about you, but not that ... If you want
my approval, then don't do the other ..’” . The result, as Mearns and Thorne note, is that
people:

struggle to keep their heads above water by trying to do and be those things which they
know will elicit approval while scrupulously avoiding or suppressing those thoughts, feel-
ings and activities that they sense will bring adverse judgement. ... They are the victims
of conditions of worth which others have imposed on them, but so great is their need for
positive approval that they accept this straightjacket rather than risk rejection by tres-
passing against the conditions set for their acceptability. (2013: 9; emphasis in original)

Such is the assault on the person's core and the onslaught against their very being that
their humanity is threatened; no longer able to trust their own inner voice, they resort
to consulting external loci of evaluation and living by others’ ideas, values and practices.
Yet, however fragile, the actualising tendency retains the potential of hope and healing.

Self and Self-Concept

For Rogers (1959), the self was the totality of human experience as it is subjectively
understood by each individual from their own unique phenomenological worldview.
An individual builds their self-concept as a result of their interactions with their world
and with others in that world; the extent to which the self-concept is constructive is
determined by the positive regard the individual receives from others when engaging
 Child and Young Person-Centred Approach 23

in behaviours that are aligned with their organismic core. The individual who introjects
others’ wishes and values into their self-concept in order to maintain their love and
affection risks such osmoses being at odds with his own organismic valuing process. The
child who draws conditionality into himself increasingly locates his loci of evaluation
externally, feeling decreasingly able to trust his own inner voice (Prever, 2010), thereby
generating a corrosive effect on the self-concept. The result is an individual who feels
progressively detached from his own organismic reality and who increasingly internal-
ises a negative self-concept which tends to perpetuate and reinforce ‘negative’ behaviour
and emotional-belief patterns (Mearns and Thorne, 2013). The experiential disorien-
tation which results in the dissonant incongruence between a self-concept which has
been infiltrated by a drip-feed of conditionality and the individual's resilient capacity
to remain wired to their organismic potential is tangible. It is the work of the person-
centred therapist to permit and enable the client to reconcile himself to that potential.
Nowhere, perhaps, are these processes more acutely noticeable than in the formative
experiences of the young. They are dependent on others for their care, less able to filter
out negative personal messages concerning them individually from significant adults
and peers, and they are often tyrannised as groups by insidious attacks from politicians,
the media and society at large. Such messages are subtle, yet strong and clear.

The Core Conditions

In 1957 Rogers published a seminal paper which famously declared that there are six
‘necessary and sufficient’ conditions required for therapeutic change:

1. Two persons are in psychological contact.

2. The first, whom we shall term the client, is in a state of incongruence, being vulnerable or
anxious.
3. The second person, whom we shall term the therapist, is congruent or integrated in the
relationship.
4. The therapist experiences unconditional positive regard for the client.
5. The therapist experiences an empathic understanding of the client's internal frame of ref-
erence and endeavours to communicate this experience to the client.
6. The communication to the client of the therapist’s empathic understanding and uncondi-
tional positive regard is to a minimal degree achieved.

Conditions 3, 4 and 5 later became known as the ‘core conditions’ and are viewed by
many therapists across modalities as the foundation for therapeutic work. The PCA
hypothesises, however, that it is solely these qualities within the therapeutic relationship
that matter in catalysing the client’s inner resources. By inference, how the therapist
24 The Handbook of Counselling Children & Young People

embodies the core conditions is of deepest concern; rather than being something that
is ‘switched on when entering the therapy room, such embodiment becomes a way of
life. This demands that the therapist takes seriously her commitment to personal devel-
opment, attunement and attending to self in supervision in order that she can fully ‘be’
with the client.
Whilst for the sake of discussion it is necessary to consider the core conditions sepa-
rately, the nature of their seamless, triune integration cannot be ignored (see Figure
2.1). Empathy, for example, cannot be understood or ‘practised’ on its own without
reference to its dynamic interrelationship with congruence and unconditional positive
regard (UPR). Together, they offer a potent way of being with oneself and with others.

Figure 2.1 A way of being (Rogers, 1980).

Congruence

The task of person-centred therapy is to nurture congruence in the client, to permit

him to reconnect with the congruent experiencing of his organismic self and to re-
enable trust in his internal locus of evaluation. Therapy seeks to minimise the distorted
gap between the client's idealised self-concept and their real self. Here, the therapist’s
congruence becomes a counterpoint to the client’s incongruence, a mirror held up to
the client that indicates not only its possibility but its desirability also. Congruence
builds trust in the therapeutic relationship (Mearns and Thorne, 2013); it expresses
 Child and Young Person-Centred Approach 25

something of the wholeness of the person, the consistency or genuineness that

exists between outward expression and inward experiencing - a gestalt, if you will.
Congruence is therefore concerned with being oneself in the moment and accurately
and appropriately representing the significance of that to and for the benefit of the
client. The therapist who is able to be in touch with herself at some deep level, and to
be accepting of that self, has a greater capacity to be attuned to the Other's process.
There is no pretence; the therapist is a person willing to accompany the client on their
journey, not an expert in the client’s life. This message when ‘conveyed’ through the
therapist's way of being moves the client from a reliance on external loci to re-building
trust in their own inner experiential voice. Congruence therefore requires the therapist
to nurture high levels of reflexive self-awareness through personal development and
supervision. Mearns and Thorne (2013: 115ff) contend that whilst the therapist must
remain intuitively aware of what is happening within her, the expression of congruent
awareness to the client must be based upon what is appropriate, relevant and persis-
tent. This is not to deny what is within the therapist’s stream of consciousness, thereby
unleashing incongruence; rather, it is beholden on the therapist to judiciously decide
what might be important to explore in her own personal development or supervision
and what should be shared with the client as a means of fostering benefit and realness
in the therapeutic relationship.
Children and young people require their relationship with their counsellor to be
trustworthy, in order that they can feel safe to explore the things they need to; secure,
in order that they can go to those often difficult, painful and challenging places with
the surety that they will be accompanied by someone real who can anchor their own
quest for reality. Congruence fosters trust. Young clients are adept at recognising those
playing a therapeutic role which is at odds with the rest of their character (Geldard and
Geldard, 2010; Geldard et al., 2013); such insincerity dissipates therapeutic value and
further undermines the client’s capacity for self-trust. Congruence is therefore central
to therapeutic work with children and young people.

Unconditional Positive Regard

Unconditional positive regard (UPR) is founded in a deep-seated regard for others’

fundamental humanity. Rogers frequently referred to UPR as ‘prizing’ the client. UPR
is the persistent attitude of actively accepting and valuing the totality of each client's
unique being and becoming, which, although it may be challenged, is not swerved by
the client’s attitude or behaviour. UPR therefore goes beyond the conditional nature of
‘liking’ to embrace a more essential attitude that deeply and warmly accepts the client
for who he is (Mearns and Thorne, 2013). Setting the client free of conditionality is
central to the process of person-centred therapy. Indeed, for Bozarth (2013: 183), UPR
26 The Handbook of Counselling Children & Young People

is the ‘curative variable’ in the therapy. The counsellor therefore must nurture accept-
ance of the client’s process wherever that may take them. For the therapist, embodying
UPRas part of her way of being is a challenge. She needs to be congruently aware of her
true feelings regarding her clients; where persistent attitudinal conditionality exists, she
must examine this with the support of her clinical supervisor.
As we noted earlier in this chapter, young people in particular are one of the most
judged groups in western societies. Developmentally they are locating through experi-
ence their own values, beliefs, ideas and practices through which they construct both
their sense of self and their place in the world (Corsaro, 2011). At times, however,
children and young people’ values and behaviours can appear to be at odds with nor-
mative adult conventions; the result is that many experience conditionality in a range
of domains. In order for therapy to be an effective counter-ballast which enables the
dissolution of conditionality and its symptoms, those working with young clients must
foster and effectively convey UPR if they are to be successful in enabling their clients’
therapeutic progress (Geldard and Geldard, 2010).

Empathy

One of the key facets of the person-centred therapeutic relationship is empathy. The
counsellor’s ability to lay down (without disconnecting from) her own phenomenologi-
cal reality and to enter the unique perceptual world of her client, to move around in
that world and to feel at home in the ebb and flow of the client’s lived experiencing of
it is arguably one of the most potent therapeutic capacities (Freire, 2013; Prever, 2010;
Smyth, 2013). Empathic expression has often been caricatured as the therapist repeat-
ing the essence of what the client has just said. Whilst empathic understanding must be
conveyed in order to be of value to the client and to meet the requirements of Rogers’
sixth condition, it is so much more. It is perceiving with accuracy the subtlety of the
client’s feelings and meanings in the totality of their emotional, spiritual, psychological
and physical being. It is conveying that understanding with tentative sensitivity to the
client in a way that enables them to absorb that their experiences and meanings have
been deeply understood and accepted by another, thereby releasing the client to do
the same on their journey towards a congruent integration of their totality. Empathy
strengthens the therapeutic alliance and enables that which is on the edge of aware-
ness to be made known. Empathy enables the conscientisation of therapeutic material:
sometimes this is as a result of ‘apparently sudden light bulb moments of realisation,
and sometimes through the slow burning of unconscious materials and meanings
which gradually slot into place in a way that gives crystallised panoramic understand-
ing’ (Bright and Harrison, 2013: 42). Empathic understanding speaks with lucidity over
the confused din of incongruence. Whilst conditions of worth lead to detachment and
 Child and Young Person-Centred Approach 27

isolation from the self and others, empathy’s gift is to enable clarity in the client’s con-
figured selves (Mearns and Thorne, 2013) and to offer connection to another who both
deeply understands and accepts the client in their being and becoming. Empathy re-
humanises the client; for Rogers (1986: 129, as cited by Freire, 2013: 167), it ‘releases
[and] confirms, it even brings the most frightened client into the human race’
The challenge to the therapist of continually suspending her own perceptual real-
ity in order to live within each client’s internal frame of reference ‘as if’ it were her
own is unmistakable. Such a ‘task’ requires time, energy, discipline, intuition, deep
listening, compassion, highly developed awareness and a willingness to take risks.
It requires a continual attunement to each client’s ‘experiences in the here-and-now
(ibid.: 168) in which the therapist must learn to flow with the client’s narrative,
meaning and emotions whilst remaining attentive to the changing landscape of the
client's inner world.

Rogers’ Seven Stages of Process

Rogers (1961: 125ff), as summarised by Casemore (2006: 11-12 in Table 2.1), offered
his view of how clients tend to process through therapy. Not all clients enter therapy at
stage one and leave at stage seven; hence the seven stages of process should be regarded
as a direction of travel in therapy rather than a matter of rigid linearity. However, it can
be used as a reference point to consider where a client might be and might be heading
in the therapeutic process; where appropriate, it might even be used with clients to dis-
cuss how they feel therapy is progressing and how they might like it to proceed.

Table 2.1 Rogers’ seven stages of process.

Stage Description

The client is very defensive, and extremely resistant to change.

The client becomes slightly less rigid, and will talk about external events or other people.
The client talks about him/herself, but as an object, and avoids discussion of present events.
The client begins to talk about deep feelings and develops a relationship with the counsellor.
OND
ar
= The client can express present emotions, and is beginning to rely more on his/her own
decision-making abilities and increasingly accepts more responsibility for his/her actions.
6 The client shows rapid growth towards congruence, and begins to develop unconditional
positive regard for others. This stage signals the end of the need for formal therapy.
7 The client is a fully functioning, self-actualising individual who is empathic and shows
unconditional positive regard for others. This individual can relate their previous therapy to
present-day real-life situations.
28 The Handbook of Counselling Children & Young People

Expressing Person-Centredness

The chapter to this point has sought to emphasise person-centred counselling’ distinc-
tiveness as a therapeutic way of being. However, to be effective, not only must the essential
nature of the therapeutic relationship be experienced, but the embodied qualities of the
therapist must also be expressed if therapeutic change is to occur (Rogers, 1957). Such
ideas are, however, elusive. Person-centred therapists need to ‘practise’ a way of being
which is congruent to them without recourse to mechanistic forms of response which
might be perceived as ‘wooden and ultimately counter-intuitive. Person-centred practice
is fundamentally about being able to capture the essence of the client's experience as it is
lived in the moment; to congruently and unconditionally accept the client in their indi-
vidual process of being and becoming. Deep listening to narrative and meaning is required
in order that the therapist can ‘lock into’ the client's internal frame of reference; however,
this understanding must also be shared with the client to facilitate their process. Perhaps
the key skill associated with this way of being is reflection. Reid and Westergaard (2011:
48) describe reflection as ‘the counsellor “holding a mirror” to their client by ensuring that
responses are appropriate and that they reflect accurately the words and feelings that the
young person is expressing. Thus, the counsellor reveals their understanding of the essence
of the client's lived experience. Person-centred therapists who are able to synchronise their
being with the client’s experience are not, however, limited to words. For some, empathic
understanding is ‘received’ through mental pictures or felt bodily sensations which, when
congruently and sensitively conveyed, can facilitate powerful therapeutic movement.

Working in a Person-Centred Way with Children and

Young People

Accompanying the client on their particular journey of growth and change is, perhaps,
most accentuated in person-centred practice with children and young people who by
the maturational nature of lifecourse experiences are very much in the process of devel-
opmental change. Geldard and Geldard (2010) and Geldard et al. (2013) contend that
therapists of all hues are most effective in practice if they are able to empathically get in
touch with their own inner child or adolescent. This, they argue, enables the therapist
to understand the child or young person’s phenomenological experience more vividly.
Person-centred practice seeks to put the client at the centre of practice. Such an asser-
tion means that those working with children and young people must appreciate the
particular needs of these age groups, to become attuned to the appropriateness of lan-
guage and expression. It has often been said that ‘play is the language of the child, and
whilst more significant coverage of this claim is offered in Chapter 7, it seems right to offer
some discussion here. Déring (2008: 41) argues that ‘Play is spontaneous, self-initiated
 Child and Young Person-Centred Approach 29

learning; it enables a child to acquire new abilities, problem-solving strategies and skills
for coping with emotional conflicts. Person-centred practice provides space for being and
exploring; for children and young people these processes take on a variety of expressions.
Behr et al. (2013) note the distinct processes in practice with children, contending that
whilst adults are able to verbalise and reflect on their experiences, children symbolise their
inner world via creative media like play, art, puppetry, stories, sand-play, dressing up and
music (the term ‘play’ will be used hereafter as shorthand for all these creative media).
Perhaps it is Rogers’ student and colleague Virginia Axline (1989 [1969]: 69-70) who is
best known for developing eight key principles for person-centred play-therapy, positing
that person-centred play therapists must become attuned to the child’s process; offering
empathic reflection of the child’s symbolisation, rather than psychodynamically-founded
interpretation of the child’s play (see Box 2.1). The language of play privileges and
beckons the therapist to enter the child’s world; it must therefore be honoured. Play must
be treated with the same dignity that is afforded to adult clients’ verbalisations. Children
will only trust the counsellor and advance in the therapeutic process when they are joined
in play and experience the being of the core conditions through the therapeutic interac-
tions which they initiate. The therapist needs, therefore, to follow the child's lead, to be
moulded by what the child does. So, when a child sits on the floor, perhaps the counsellor
should to do the same. Such practice also begins to mitigate inherent power differentials
that can exist between client and counsellor; it emphasises the value the counsellor has for
the child and fosters equality in the relationship (Smyth, 2013).

Box 2.1

James is busy lying on the floor, drawing a picture. The therapist lies next to him, sup-
porting his chin in his hands.
Therapist: ‘It looks like you are drawing a playground with a swing, a roundabout
and a climbing frame?’
James: ‘Uh-huh:
Therapist: ‘The playground looks as if it’s in a park?’
James: ‘Yes.
Therapist: ‘There’s a boy playing in the park?’
James: 'That’s me.
Therapist: ‘You've drawn a bench?’
James: No reply (silently concentrating)
Therapist: ‘It looks as if you are sitting on the bench on your own?’
James (smiling
reflectively): ‘Yes, | like to be alone. | like the peace:
(Continued)
30 The Handbook of Counselling Children & Young People

(Continued)
Therapist: ‘Peace?’ ;
James: ‘Yeah, | never get it at home - mum and dad are - arguing as
then | have to share a room with two of my brothers..

Adolescence is a time of profound emotional, social, physical, sexual, psychological,

familial and educational change (Coleman, 2010). During this period, the process of
being and becoming is perhaps highlighted more than any other. Person-centred work
affords young people the space to be, to individuate, to clarify perspectives, to gain new
insight and to manage relational boundaries between self and others (Bright, 2013).
Working with young people during this period of their lives can be both challenging
and richly rewarding as together counsellor and client observe the person who begins
to emerge from the chrysalis. During this phase, young people often change their
communication preferences, becoming increasingly likely to talk rather than use
creative media. Adolescent communication is affected by a range of factors including
culture, environment, age-related development and even time of day. Many young people
feel a distrust of adults, who they perceive don’t understand them (Hawkins, 2008);
counsellors working with adolescents therefore must learn to empathically enter each
client's phenomenological and linguistic reality and to convey their understanding of
the client’s internal frame of reference by paralleling the young person's communica-
tion processes (Geldard and Geldard, 2010). Such practice fosters relational security
between client and therapist and builds the young person’s sense of inter-connectedness
(Smyth, 2013).

Short-Term Work

As we have noted, the PCA is concerned with placing the client at the heart of practice.
It expresses empowerment, democracy and the promotion of client autonomy as foun-
dational principles. Merry (2008: 12) contends that the PCA above all others affirms
an ‘enduring commitment to encounter clients in a direct, person-to-person manner
without providing a set of rules ... that control the process. Indeed, Smyth (2013: 163)
argues that time-limited work in person-centred practice is ‘anathema. Externally
imposed time constraints potentially limit the client's capacity to engage fully in the
therapeutic process, and may result in ‘rushing’ the client towards a premature ending,
thereby undermining hard-won therapeutic gains. The PCA holds that the decision to
end therapy should be the client's in conjunction with the therapist. Externally imposed
time restrictions can place counsellors under significant pressure to direct clients
 Child and Young Person-Centred Approach 31

towards conclusions before they are ready, resulting in practice that may be unethi-
cal. The PCA therefore finds itself increasingly at odds with the assimilated wisdom
of other approaches and funders’ preferences for time-limited work. Pragmatically,
Mearns and Thorne (2013) suggest that counselling agencies might seek to negotiate
an average of, say, six sessions per client; doing so, they argue, allows practitioners to
manage caseloads more effectively whilst maintaining the integrity of the approach. In
practice, ‘surplus’ sessions from one client can then be allocated to others.

ic ~
Case Study Sarah
Sixteen-year-old ‘Sarah’ was referred to me for counselling by ‘Des; her Connexions Adviser. She had found
school educationally disengaging and socially difficult. Sarah was also coming to terms with the recent
break-up of her parents’ relationship. Living with her dad, she had hardly left the house since leaving school
three months previously. Sarah didn’t want to engage with friends, and despite her love of drama felt una-
ble be part of any group activity.
| saw Sarah for six sessions. During the first two, she was unable to look at me and spoke very little.
| was aware, however, of a very damaging self-concept. As the sessions progressed, | began to ques-
tion what help | (as a trainee counsellor) could be to a client who would barely speak and offered very
little eye contact. | wondered whether | should integrate other approaches into my work with this
client. In truth, | found the experience of working with Sarah quite disarming. In exploring this with
my supervisor, | became aware of my need to rescue my client, of my need for my client to ‘improve’ in
order to validate me. |was encouraged to trust the client’s process, to be with her as she was, to listen
empathically to her in her speaking and in her silence. | had come to realise that my expectations of
Sarah's processes were counter-therapeutic, and were compounding the conditions of worth that
she had experienced.Tomy amazement, Sarah continued to come willingly each week, slowly saying
more about her experiencing and owning more of her own story. Sarah allowed me to listen beyond
words, to experience empathy in the silence.
Weeks later Des called me to say that Sarah was a ‘different person’ She was volunteering at a local
youth project, involved in a drama group and enrolling on a training course. Des asked Sarah what
had made the difference. ‘Counselling’ she replied. ‘Graham just allowed me to be there’
| learned to trust the client’s process!
ior 2)
Research

The person-centred world appears engaged in some considerable debate concerning

its involvement in particular forms of evidenced-based research, which some argue are
counter-intuitive to its humanistic-phenomenological axiology. Others, meanwhile, contend
 32 The Handbook of Counselling Children & Young People

that Rogers himself was an empiricist who engaged in rigorous forms of research which
were concerned with both process and outcomes in therapy. Whilst there have been
recent moves to produce efficacy studies via randomised controlled trials and meta-
analyses on wider population studies, little has yet been specifically developed regarding
the efficacy of the person-centred approach with children and young people. This picture,
however, is slowly changing, thanks to the pathbreaking work of Professor Mick Cooper
and colleagues who are generating interesting evidence bases regarding the efficacy of
humanistically-based therapies in secondary schools (see Cooper, 2009a, 2013; Cooper
et al., 2010, 2013; McArthur et al., 2013).

Summary

This chapter has:

e Outlined the central ideas of the person-centred approach

e Considered the Rogerian postulation that particular qualities expressed within the counsel-
ling relationship are the singular requirement for therapeutic change and growth
e Explored the challenge of these relational qualities as a ‘way of being’ for the counsellor in
accompanying the client in their journey of being and becoming
e Offered application of these principles to therapeutic practice with children and young people
with particular reference to Axline’s ideas on creativity and play as symbolisation of the child’s
inner world

Reflective Questions

1, Rogers contended that the six conditions that he outlined in his 1957 paper were ‘neces-
sary and sufficient’
fortherapeutic change. What is your view of his assertion?
2. How effective are you in offering the core conditions to clients? What might your clients
say? What might be different?
3. The person-centred approach is concerned with therapist embodiment of a way of being.
What are the particular challenges of this idea within your own personal development
and professional practice?
4. Rogers (1961) proposed his seven stages of process. Map the process of a client you have
been working with. What might be learned here?

There are no specific answers to the questions - you are asked to reflect and use your
own experiences.
 Child and Young Person-Centred Approach 33

®
i
Learning Activities

Theory suggests that psychological distress occurs when we adapt our being and behaviour
to meet others’ demands, values and expectations. This generates disconnects between
Our organismic or core self and our self-concept. This, as | have argued, is particularly perti-
nent in work with children and young people.
Answer the following for yourself, then discuss appropriately with others (a peer, per-
sonal therapist or supervisor perhaps).

1. What conditions of worth or introjected values can you identify as having influenced
your own way of being?
2. Thematically, what conditions of worth might you identify as salient for clients with
whom you have worked? Where do these originate?

The PCA is a‘way of being’ with self and others.

Explore with another:

3. How this challenges you, personally and professionally.

4. How accessible is your own inner child/adolescent?
s ?

Further Reading

Cooper, M., O'Hara, M., Schmid, P.F and Bohart, A.C. (eds) (2013) The Handbook of Person-Centred
Psychotherapy and Counselling. Basingstoke: Palgrave Macmillan.
This excellent and recently revised compendium on the person-centred approach examines
theoretical concepts, underpinning values and contemporary debates and practices.

Mearns, D. and Thorne, B. with McLeod, J. (2013) Person-Centred Counselling in Action. 4th edn.
London: SAGE.
This classic text, now in its fourth edition, from these doyens of the approach is known as‘the Bible’

Merry, T. (2008) Learning and Being in Person-Centred Counselling, 2nd edn. Ross-on-Wye: PCCS
Books.
A warm, accessible introduction to the person-centred approach.

(Continued)
34 The Handbook of Counselling Children & Young People

(Continued)

Prever, M. (2010) Counselling and Supporting Children and Young People:APerson-Centred Approach.
London: SAGE.
Mark Prever’s book is a much needed addition to the literature. It examines the person-centred
approach with clarity and offers excellent application to practising counsellors and other profes-
sionals working with children and young people.

Smyth, D. (2013) Person-Centred Therapy with Children and Young People. London: SAGE.
David Smyth's book is written with rigour and warmth. This is a text that draws wisdom from the
wells of practice.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially Modules CM 07: Relational Skills,
and CM 08:Therapeutic Skills.
 Psychodynamic Approaches
Sue Kegerreis and Nick Midgley

This chapter includes:

LS LT LL DI EES EIOT ILL LEEDS EEEIS LITE SEE LESLIE SLICES SOS LES ITT EERE GENET,

e An outline ofthe history of psychodynamic ideas

e An account of the particular features of the psychodynamic approach to work with children
and adolescents
e Suggestions regarding the applications of psychodynamic thinking in different settings
e A brief description of a case illustrating the key concepts and elements in use in psychodynamic
practice
e A description of recent research into the efficacy of psychodynamic treatment with children
and adolescents.

Background and History

Psychodynamic psychotherapy with children and young people has its origins in the
work of Sigmund Freud. First in The Interpretation of Dreams (1900) and then in Three
Essays on the Theory of Sexuality (1905), he suggested that our behaviour is governed
by unconscious processes, and that mental disturbances (and indeed the core of our
personality itself) can often be traced back to key aspects of early childhood experi-
ence. He also argued that mental and emotional difficulties can be addressed through
a therapeutic relationship that assumes that behaviour has meaning, and that exploring
and coming to some understanding of one’s ‘internal world’ is a key element of emo-
tional well-being.
36 The Handbook of Counselling Children & Young People

Although he worked primarily with adults, Freud was interested in the way his ideas
could be used to help children, although at first he thought this was best done by sup-
porting parents. In his famous case study of ‘Little Hans’ (1909), he offered a series of
‘parent consultations’ to the father of a five-year-old boy with a phobia about horses, in
which he encouraged the father to pay attention to his son’s anxieties and to take seri-
ously the way in which this worried little boy was making sense of the world around
him. Freud demonstrated that taking the child’s view of the world as genuinely mean-
ingful and taking time to listen to him was in itself therapeutic, although he thought at
the time that only a parent would have the kind of relationship that would make this
type of work possible.
It was left to the next generation of psychoanalysts - including Hermine Hug-
Hellmuth (1921), Melanie Klein (1932) and Anna Freud (1974 [1927]) — to demonstrate
the possibilities of direct work with children. These early analysts differed on many
points of theory and technique, but they were all agreed that children’s difficulties
could be understood by paying attention to the ‘internal world’ of the child, and that
establishing therapeutic settings in which this internal world could be explored safely
was key to therapeutic change. They agreed that play was central to the way in which
children communicated about their internal worlds, and that children often play out
in their relationship to the therapist (the transference) some of the key elements of
their internal drama. Later psychoanalysts also came to see that the emotional expe-
rience of the therapist him- or herself (the counter-transference) could be a source
of information about the child’s inner world and, furthermore, that being able to
manage strong counter-transference feelings was a key to successful therapeutic work
(Heimann, 1950).
Many of the most influential psychoanalysts of the second half of the 20th century
developed their ideas through working with children. Winnicott (1958) recognised
the role of the parent-child relationship in supporting healthy emotional develop-
ment. He also saw that not all unconscious mental processes had to be verbally
interpreted in order to be therapeutic. For Winnicott, play itself had therapeutic
value — an idea that builds bridges with the work of play therapists such as Axline
(1990 [1971]). Meanwhile, Anna Freud was coming to see that not all childhood
disorders were necessarily based on internal conflicts (as Sigmund Freud had sup-
posed). In Normality and Pathology (1965), she came to the opinion that for some
children their difficulties were based on ‘deficits’ in their early experience (whether
due to trauma and neglect or to genetic or biological causes - or indeed a com-
bination of both). Meanwhile Bion (1962) introduced the important concept of
‘containment; i.e. that a child’s development depends on the capacity of the adults
to receive and metabolise the child’s powerful emotional experiences, and return
them to the child in a way that could be properly processed. Without this the child’s
inner experiences are more likely to be overwhelming and manifest as emotional or
behavioural problems.
 Psychodynamic Approaches 37

a Case Study Paolo *

Paolo,’ eight, was referred to the school counsellor because he was hitting other children, constantly
distracted in class and lacking the concentration to learn effectively. Staff felt that he was intelligent
but was underachieving. A psychologist found him to have a mild degree of attention deficit disorder
but not to be hyperactive. Paolo's parents were caring and concerned, seeing the problem mainly in
terms of him not applying himself -although they were aware also of him preferring to be in a world
of his own. He resisted attempts to be taken out on family outings, preferring to play games on his
phone or computer. He had always seemed ‘different’, but they had not seen him as having problems
until the demands of school began to bite.
In the assessment meetings, Paolo played rather formless games with the cars and other toys.
Some had a narrative of sorts, with animals gobbling each other up or attacking each other in shifting
alliances, but relationships between the toys were perfunctory or unclear, and the play meandered
without much focus. After a while, the counsellor felt completely at sea, beginning to think that she
had lost her expertise in understanding children or maybe never had any. Although she was an expe-
rienced counsellor who had worked with many hard-to-reach children, she felt unable to make a link
with Paolo, who related to her in an affable but impersonal way.
er s)

What does this tell us about psychodynamic counselling or therapy? And why would
it help the therapist - and, more importantly, Paolo himself — if the therapist is able to
think psychodynamically to try and make sense of what was going on in these assess-
ment meetings? Below we will set out key elements of psychodynamic counselling and
psychotherapy,’ and show how this way of thinking and working can be of value when
facing situations such as this.
Contemporary psychodynamic therapy with children and young people builds on
many of these key ideas, and has developed in somewhat different ways in different
cultures (see Geissmann and Geissmann, 1998). Psychodynamic therapists also inte-
grate findings from other disciplines such as developmental psychology, attachment
theory and neuroscience to enrich their clinical and research work (e.g. Green, 2003;

! For reasons of confidentiality this case is a fictionalised and disguised amalgamation of

several actual cases.
2 In this paper ‘counselling’ and ‘therapy’ will be used interchangeably although the authors are
aware that these terms have different histories and are often linked to different trainings and
professional groups. The term ‘psychodynamic’ is used to cover a broad range of approaches,
all of which have their roots in psychoanalytic thinking, but which have developed in a number
of different directions. As described in this chapter, most contemporary psychodynamic
thinking is also integrated with findings from other disciplines, such as attachment theory,
neuroscience and developmental psychology.
38 The Handbook of Counselling Children & Young People

Horne and Lanyado, 2012; Alvarez, 2012). Psychodynamic child therapists are also
influenced by systemic thinking, in particular the idea that understanding a child’s
problems involves an appreciation of the system in which they live; and that working
with that system is as important as working with the child’s internal world.

Skills, Attitudes and Beliefs Necessary for a Psychodynamic

Practitioner

The core skills and attitudes needed in a psychodynamic practitioner follow directly
from the set of beliefs on which they are based. As indicated above, the central idea is
that behaviour, emotions and responses have an inherent logic and meaning — a way in
which the child’s problems, despite their apparent unhelpfulness, make some kind of
emotional sense. Their roots lie in the internal world of the child that has been built up
from his earliest experiences and relationships.
If a child has been presented with experiences that are hurtful, frightening or which
engender internal conflict (which will always be the case to some degree), he or she will
have built up defences to make the emotional pain less overwhelming, and to keep out
of awareness whatever is more than can be coped with. This is often related to how dif-
ficult his beginnings have been, but not inevitably or simply, as some children are more
resilient than others - making surprisingly good progress in relatively impoverished or
damaging circumstances - while others are much more sensitive and vulnerable.
The real relationships and circumstances in children’s lives are, of course, crucial influ-
ences on how they feel about themselves and others, and family or parental work is often
indicated to help address ongoing difficulties in home relationships. However, in psychody-
namic work the focus will be on how children have internalised a ‘cast of characters’ in their
mind, a set of ‘ways of being with others’ (Stern, 1985) and a set of ideas and beliefs about
themselves and relationships which powerfully dictate how they behave and respond. They
need new, good experiences, but for some this is not enough, and they can be held in these
patterns because of the greater vulnerability they would have to manage and the pain they
would have to face if they were to lower their defences and experience the world more as it
actually is, rather than through the lenses established from earlier experiences. Of course
if the world is still unsafe then it may not be appropriate to expect the child to make such
changes, and the priority is to work with the network around the child to help create a more
supportive environment. In reality, this is not usually an either/or situation, as changes in a
child can impact on the environment around them, as well as vice versa.
From this underlying set of ideas follows the key elements of psychodynamic prac-
tice. First, the practitioner has to observe extremely carefully how the child acts, reacts,
responds and relates, as expressed in the way the child speaks, plays and behaves but also,
crucially, in how it appears he is experiencing the therapist. This emotionally sensitive
 Psychodynamic Approaches 39

and informed observation will reveal information about the internal world of the child.
The therapist will be alert to clues as to what anxieties the child is most affected by, what
defences he is using to keep vulnerability at manageable levels, what sorts of experiences
appear to have been indigestible and what inner conflicts are causing the child’s develop-
ment to have stalled or become disrupted.
Putting observation first does not preclude the counsellor interacting in a lively
way with the child — far from it. The counsellor offers a thoughtful presence, perhaps
putting into words what he is doing and showing or commenting on what the play is
conveying. However, it does mean that the counsellor will most likely let the child lead
the session, usually avoiding setting agendas or dictating activities. She might join in
play with the child, but would take care to remain reflective and alert to the emotional
dynamics, seeking guidance from the child as to what part she is supposed to play, and
all the time keeping one foot outside the game, reflecting and maybe commenting on
what is being brought into focus through the play. As the main aim is to find out what
is going on in the child’s mind and emotional life, it is essential that the child’s own
preoccupations are allowed to emerge rather than that the practitioner impose a shape
on the sessions.
Alongside observation, the counsellor looks for ways of putting words to the child’s
experience. Giving children an emotional vocabulary is often of key therapeutic value,
partly because this offers acceptance and validation of often shaming or painful emotions
the child may have, but also because the act of naming a feeling makes it accessible to
thinking, giving it a shape and substance that can render it less overwhelming and more
available to be processed. Feeling understood is in itself a powerful therapeutic agent.
So the counsellor observes and is perhaps able to comment or put into words some-
thing that the child is revealing but may not be consciously able to think about. This
might, as already indicated, be about the child’s inner feelings and emotional conflicts
and anxieties, but it might be more explicitly about the relationships the child habitu-
ally experiences.
This brings us to another central plank in psychodynamic thinking — the transference.
The way the child responds to us in the therapy room is often a direct communication
about how they have internalised their earlier experiences with others. We get infor-
mation from them as the relationship develops as to how they see us, what issues they
have with us (feeling badly treated, wanting to be the sole focus of our attention, being
afraid of disapproval, expecting us to be punitive, seeing us as useless and so on) which
are good indications of the perceptions they are prone to have of others in their lives
and clues as to how they have experienced aspects of their first and most important
relationships. Some of this may be of relatively recent origin, but a psychodynamic
practitioner will also be attentive to indications of the nature of the infantile transfer-
ence — that is, feelings in relation to the therapist that hark back to the child’s earliest
experiences, when they were at their most vulnerable and when their capacity to pro-
cess experience was at its most primitive.
40 The Handbook of Counselling Children & Young People

Alongside this the therapist will be paying attention to their own emotional state,
reactions and responses, using these to provide another level of information about the
child — the counter-transference. The child may be relating to the therapist so that the
therapist feels something the child himself feels consciously or unconsciously, such
as fear, despair, frustration, vulnerability, stupidity. The therapist here is being asked
to register and bear feelings which the child himself may not be able to manage. Or,
in a variation on this theme, the therapist may find herself responding as if she is a
figure from his inner world, perhaps feeling rejecting, detached, mindless, punitive
or placatory. This can carry vital information about the unhelpful responses the child
engenders in those he meets — based on experiences of his first relationships.
So the psychodynamic therapist is constantly using this binocular vision, monitoring
both the child’s way of relating and her own emotional state. First she has to manage
the impact of these, then she has to work out whether, when and how to put some of
this into words for the child. If she manages to remain curious and thoughtful while
registering and digesting the impact of the child - without getting caught up in the urge
to respond in kind or retaliate - she is offering him ‘containment’ (Bion, 1962). This
can be therapeutic in itself and is of great value in both clinical and non-clinical set-
tings. The therapist’s processing and understanding may be sufficient to free the child,
without this having to be interpreted. However, sometimes a timely and simple inter-
pretation of what she has understood will help the child make sense of his own feelings
and liberate him from being driven endlessly to repeat the same dynamics.
It becomes clear from these considerations that some personal attributes are essential
for working psychodynamically. Practitioners need to have a high level of self-awareness
and self-knowledge, as they are using themselves as the central tool of the therapy. They
need to be substantially in charge of their own feelings, so they can use their responses
as a sensitive barometer for the dynamics in the room, without resorting to reaction or
blocking the impact of the child on them. They need to be endlessly curious as to what
might lie behind a child behaving or relating as they do, and above all be prepared to
manage receiving the child's negative as well as positive responses.

Using Psychodynamic Approaches across the Age and Ability

Range

One of the beauties of the psychodynamic approach is that it can be adapted to work with
such a wide range of children, both in age and in intellectual capacity. Psychodynamic
work can take place in classrooms, children’s homes or in hospitals, as well as in consulting
rooms, with individuals or with groups (see Lanyado and Horne, 2009; Kegerreis, 2010;
Schmidt Neven, 2010). Because of its focus on emotional communication and interper-
sonal dynamics, and because so much of the work can be done through art and play, and
through the capacity of the therapist to process the relationship dynamics brought to life
 Psychodynamic Approaches 41

by the child, much can be done with children who are not particularly verbal as well as
those who want to talk and who can understand at a sophisticated level.
The kind of language used and the means of expression for the child will of course vary
depending on the age and developmental stage of the child. With younger children a great
deal of the work will be conducted through art and play, with much of the processing done
within the practitioner's mind and any interpretation geared sensitively to the child’s level
of linguistic ability and understanding. With older children and adolescents more will be
done verbally, and interpretations may be more elaborate, making more explicit the pat-
terns observed and their links with those from the family or from the past.
Whatever the age of the client, however, what is therapeutic and brings about change
is often less the explicit working out of a narrative link between past and present but
more the way in which, during the therapy, the old and now out-of-date relationships are
recreated, but this time worked through differently, with the therapist able to be thought-
ful about the dynamics, reflecting on and having insight into and curiosity about their
meaning, rather than just responding or retaliating. In Anna Freud’s words, the therapist
is both a ‘transference object’ but also a ‘new object; offering the child a different kind of
experience and thereby promoting the child’s own capacity to accept and welcome new
experiences (Hurry, 1998).
As it focuses so closely on the way in ach the world is subjectively experienced
by the child, the psychodynamic approach can be also used helpfully across cultures,
encouraging genuine curiosity about cultural differences and how they are experienced
by each individual. Undeniably a therapist must be sensitive to how a different cul-
ture may have shaped the child’s start in life and current milieu. She also needs to be
alert to her own limitations in understanding how different their experiences might be,
including the child’s perception of her and the therapeutic setting. She must register
and process the ‘cultural transference’ (e.g. Gibbs, 2009), and pay attention to real dif-
ferences in terms of cultural and social inequalities. The psychodynamic counsellor
also needs to explore her own cultural positioning and recognise her own ‘internal
racism (e.g. Davids, 2011). However, the emphasis on the sense the child is making of
their individual world means that psychodynamic approaches can be used to address
whatever conflicts and vulnerabilities are getting in the child’s way, as well as assisting
the child in processing the meaning of their own cultural journey.

Using the Psychodynamic Approach in Short-Term Work

If the essence of psychodynamic therapy is the reconfiguring of a child’s inner

world, removing unhelpful defences and installing more benign inner objects, then
it is true that this work can take a long time, as it involves major restructuring of
the child’s way of relating to the world, itself dependent on making it first safe
enough to do so.
 42 The Handbook of Counselling Children & Young People

However, another central element in the psychodynamic approach is the bringing of

unconscious elements to the surface and becoming aware of internal conflicts. Particularly
with older children and adolescents, it is possible to help a client swiftly by helping them see
what internal conflicts lie hidden in their presenting problems. They feel stuck, trying to
change a behaviour which they can see is unhelpful to them, but unable to change because
they are not in touch with the underlying reason for, and meaning of, the behaviour. For
example, Sam, 15, was consciously desperate to do well in his GCSEs, so as to impress the
father who had left two years earlier and to be in a position to follow in his footsteps. But
he found himself endlessly procrastinating and avoiding his revision. In therapy it was
quickly possible for the first time for his deep hurt and anger with his father to come to the
surface, making him aware of the unconscious sabotage going on. Once this was conscious
he found it much easier to make himself work, on his own behalf rather than in an attempt
to resolve his emotional difficulties with his father. Longer-term work might have led to
deeper levels of meaning and other kinds of changes. But short-term work enabled Sam to
deal with the specific problem he was facing — his problems preparing for his exams — and
also awakened in him a curiosity about the links between his behaviour and his deeper
thoughts and feelings about the people around him.
Uncovering patterns, making links that are as yet unacknowledged and recognis-
ing ambivalent feelings are ways in which psychodynamic work can be effective even
though brief. Sometimes it is enough for a child or adolescent to have their feelings
recognised, named and validated. Many young people are in families where, for what-
ever reason, the way they feel or how they are experiencing things is difficult for their
carers to acknowledge. Maybe it is too painful for a parent to see their child’s distress,
or the parent's own past is so vivid in their mind that they find it hard to see their child
clearly in their own right. Coming to therapy can give a child a chance to have their real
feelings witnessed, accepted as real, named and understood in a way that is immensely
healing in its own right. This can be helpful in a short intervention, making space for
the child’s own developmental drive to reassert itself.

~
Returning to Paolo
At the start of this chapter we introduced Paolo, and left him at the point where he was being
assessed by a psychodynamic counsellor at school, who was left feeling rather de-skilled after her
initial meetings with him, in which his play seemed to be formless and without meaning. But the
therapist was, after the discomfort of these initial feelings, able to draw on her psychodynamic
thinking and to process her counter-transference in a number of ways. First, she realised that her
lack of connection with Paolo was not just her own failure but was similar to how the staff at school
 Psychodynamic Approaches 43

=
and, to some extent, his parents felt. Second, she realised that her experience of nothing making
much sense and the links between things being obscure and/or arbitrary was an indication of how
this child experienced his world.
In treatment with Paolo, she put these experiences and thoughts into words. He let her know how
much difficulty he had in getting properly in touch with, let alone making sense of, his feelings. His
recourse to repetitive games was in part a retreat from what baffled and perplexed him in the real
world of other people. He sought distraction and excitement in a fantasy world that offered escape
from his sense of disconnection and disarray. Given his difficulty in staying in touch with reality, it was
not surprising that applying himself to learning was a challenge.
One important strand in the work with Paolo consisted in the therapist helping him grasp and
identify his own feelings. Another consisted of her first registering, then processing and bearing,
then being able to feed back to him the experience - clearly one he had himself struggled with —
of not being emotionally connected. His parents were kind, but for a range of reasons had not
been consistently able to reach out and try to understand this little boy. They were very practical
in outlook, pragmatically unwilling to address their own emotional agendas and troubled mar-
riage, and coped by addressing behaviour but not emotions. Paolo responded strongly to the
therapist's interest in his emotional life and week by week built better links both inside himself
and between himself and others. His play became more coherent, with clear narratives and con-
sistent relationships. He calmed down, as he no longer needed to distract himself so much from
his own confusion. As he became more at ease inside his own head, as it were, he began to be
able to learn. He was also increasingly able to mentalise, which meant that his capacity to relate
to other children improved (Midgley and Vrouva, 2012). Regular meetings with his parents also
helped them to see the importance of looking beyond Paolo’s behaviour and seeing him as a
child with his own mind and his own feelings. When the counsellor was able to help the parents
recognise their own resistance to doing this, they were also able to acknowledge their own
need to address issues in the parental relationship, and made a decision to attend a service that
offered counselling for couples.

Research, Including Evidence-Based Practice and Practice-Based

Evidence

A case example such as the one about Paolo, above, might suggest that psychodynamic
counselling or therapy can be helpful for children, but there is always a danger that
we generalise too much from specific experiences, or that we remember those inter-
ventions that were helpful and find reasons to forget or excuse those times when our
approach did not seem to be so useful. For many years psychoanalytic and psycho-
dynamic therapies have been considered to lack a credible evidence base and have
44 The Handbook of Counselling Children & Young People

consistently failed to appear in lists of ‘empirically-supported treatments. Partly this

has been due to a degree of reluctance among psychodynamic practitioners to support
the kind of empirical research that could establish such an evidence base, whilst other
approaches — especially cognitive-behavioural therapy - appear to have been more
active, but it is also due to the fact that the research which has been done has not been
gathered together and widely disseminated.
In the field of psychodynamic treatment of adults, recent years have seen the
publication of a series of important reviews and meta-analyses culminating in the
landmark publication of Jonathan Shedler’s paper on “The efficacy of psychodynamic
psychotherapy’ (Shedler, 2010). This paper brought together the evidence from a
number of randomised controlled trials, showing that effect sizes for psychodynamic
therapies are at least equal to those of other forms of treatment long regarded as
‘evidence-based’, and that patients who receive such treatment not only appear to
maintain their therapeutic gains after treatment ends but in many instances continue
to improve.
Research examining the efficacy and effectiveness of psychodynamic treatments
for children and adolescents has lagged behind the equivalent with adults, although
there exist a rich clinical literature and a strong tradition of qualitative, practice-based
research (see Midgley et al., 2009). However, this situation is changing, with many more
studies now being completed. A systematic review of the evidence base for psycho-
dynamic therapy with children (Midgley and Kennedy, 2011) used 34 separate studies,
including nine randomised controlled trials (RCTs), to provide as complete a picture as
possible of the existing evidence base for individual psychodynamic psychotherapy for
children aged between three and 18.
Key conclusions of the review included the following:

e Studies of psychodynamic therapies indicate that this treatment can be effective for a
range of childhood disorders, as measured by well-validated, standardised research
instruments.
e Psychodynamic treatment of children and adolescents appears to be equally effective
when directly compared to other treatments, with mixed findings across studies — some
suggesting psychodynamic therapy is more, some less, and some equally effective as
other forms of therapy.
e Psychodynamic treatment may have a different pattern of effect to other treatments.
For example, depressed children appeared to recover more quickly if given family
therapy, whilst improvements for those receiving individual psychodynamic therapy
appeared to be slower but more sustained, with some young people continuing to
improve after the end of treatment. A similar pattern of more gradual improvement,
but with improvement continuing beyond the end of treatment, was found in a study
of children with emotional disorders, giving some evidence of a possible ‘sleeper effect’
in psychodynamic therapy.
 Psychodynamic Approaches 45

¢ Younger children appearto benefit more than older ones, with the likelihood of improve-
ment during treatment declining with age. However, older children and adolescents can
also benefit from psychodynamic therapy.
¢ Children with emotional or internalising disorders seem to respond better than those
with disruptive/externalising disorders, with an especially strong evidence base emerg-
ing for the treatment of children and young people with depression.
e Children and adolescents with disruptive disorders are more difficult to engage and more
likely to drop out of psychodynamic treatment; but where they have engaged in treat-
ment there is some evidence that it can be effective.
e Arange of studies suggests that psychodynamic work is effective with children who have
experienced abuse, maltreatment and trauma, although the group is too diagnostically
diverse for this to be reflected in empirically-supported treatment guidelines.
e Insamples that apparently had lesser degrees ofdifficulty either because of the setting or
selection criteria, short-term and even minimal interventions were shown to be effective.
e There were some indications of potential adverse effects, especially if therapy was offered to
children without parallel work with parents or if it added to an adolescent's sense of‘stigma’

One positive message taken from this review is that the amount of research investigat-
ing the efficacy and/or the effectiveness of psychodynamic psychotherapy with children
and adolescents has increased decade by decade from the 1970s. This is a promising
sign that we are beginning to gain some understanding of ‘what works for whom’ in
regard to psychodynamic treatments for children and young people.

Concluding Remarks

The psychodynamic approach emphasises three main distinctive features:

1. the power of unconscious dynamics at work in all of us;

2. the central importance of early experiences in shaping how we perceive, experience,
behave and relate;
3. the use of the therapy relationship itself in bringing about both insight and change.

Out of these core features come key techniques and attitudes. The therapist uses her own
observational skills to elucidate the inner world of the child. The child may play, use art
materials and/or talk, and from this and the evolving relationship with her, the thera-
pist gains insight into what conflicts, anxieties and defences are at work and how these
are interfering with the child making the most of their opportunities and relationships.
She processes all this and feeds back to the child where appropriate, while appreciating
that the receiving and understanding of the child’s feelings and providing the child with
opportunities for emotional expression and exploration may be powerfully therapeutic
in themselves.
 46 The Handbook of Counselling Children & Young People

While it has its roots in psychoanalysis, psychodynamic work with children has been
modified and extended to meet contemporary challenges. In response to theoretical
refinements, clinical experience, different client groups, new knowledge about child
development and input from many other kinds of psychological and therapeutic under-
standing, it now offers a flexible yet powerful tool to help a wide range of children.
Furthermore, because it also offers so much understanding of the impact of troubled
children and families on those who work with them, and the complexity of professional
interactions around challenging cases, it can be used effectively in non-clinical as well
as clinical settings and to help staff as well as children and families (Nicholson et al.,
2011; Kegerreis, 2011).

Summary

e Psychodynamic work with children and adolescents has evolved from its psychoanalytic ori-
gins into an adaptable and practical approach to the problems of young people
e The psychodynamic approach requires from practitioners particular qualities of observational
skill, self-awareness and emotional sensitivity
e Psychodynamic therapy enables children to experience and identify their feelings more fully
and have these feelings witnessed, validated and understood
e Psychodynamic therapy aims to help children develop more benign inner worlds, which in
turn can foster better feelings about themselves and better relationships with others
e There is increasing evidence that psychodynamic therapy can be helpful for a wide range of
children and adolescents, but there is a need for more high-quality research in this area

Reflective Questions

1 How does the psychodynamic approach enable children to gain

greater control over their behaviour?

The therapist helps the children become aware of unconscious factors influencing how
they perceive, behave and relate to others. Once conscious, these factors lose some of
their power and are more susceptible to conscious control. Thought and/or talk can
then take the place of action. The psychodynamic approach would suggest that a child’s
difficult behaviour arises from defences which have outlived their usefulness and are,
in fact, causing greater problems and/or cutting the child off from internal resources
and external support. The therapy will help the child relinquish some of these defences
so they can develop more creative and mutually enriching relationships with those
around them and have better access to their own resources.
 Psychodynamic Approaches 47

2 Does psychodynamic thinking suggest that children with

abusive pasts are bound to get into abusive relationships
later in life?

Psychodynamic thinking helps explain repetitive patterns in relationships (e.g. Klein’s

concept of the ‘inner world’ and ‘projective identification, Freud’s view of ‘repeti-
tion compulsion’ and Anna Freud's ideas about ‘identification with the aggressor’).
Unconscious factors can lead children who have abusive pasts to find themselves in
abusive relationships later in life. However, while our past influences our future, this
is not deterministic. Good relationships mitigate the effects of damaging ones and our
inner worlds are constantly changing.

3 Why is it useful in psychodynamic work for the setting and the

time of sessions to be kept as much the same as possible?

It takes courage for a child to engage with us, lower their defences and allow themselves
to open up and become more vulnerable in their work with us, so it is vital that we create
a containing environment, with safety and regularity essential. If we are to make it
safe for them to experience and work through difficult feelings, including re-encountering
relationship difficulties through their experiences with us, then we have to make sure
they know we will be there for them in a regular and reliable way, whatever comes up
in sessions. Second, if we keep the ‘frame’ as stable as possible, it is easier to perceive
what it is that they themselves are bringing into the situation. The specific emotional
environment brought into being by each child can more accurately be discerned if
everything else is kept constant.

4 Why would a psychodynamic practitioner pay a lot of attention

to how they were feeling in their interactions with clients?

It is a central tenet of psychodynamic understanding that we project difficult feelings into

one another, to get rid of them and/or in the hope that someone will be able to process
them and help us manage them. Therefore we as therapists monitor the way a client makes
us feel (the counter-transference) as it may contain important information about their
emotional world, as well as our own. We consider that our capacity to register, process and
make sense of how our clients make us feel and react is a key element in working through
their emotional difficulties.
48 The Handbook of Counselling Children & Young People

5 Why is the psychodynamic approach applicable to children

of all ages?

We concentrate on the subjective reality of the child, with particular attention paid to
early experience and the quality of the relationship created between child and therapist,
so there is no age of child — or adult - with whom the psychodynamic approach is not rel-
evant. Most psychodynamic practitioners’ training includes the observation of an infant
from birth, so we are used to thinking about the earliest levels of experiencing. Work can
be done with both verbal and non-verbal communication. Understanding child develop-
ment and the particular tasks of each stage are central to all trainings, as is the capacity to
communicate with children of all ages. At the other end of the spectrum psychodynamic
work has also been applied to work with all ages of adults, including the elderly.

¢ ?
Learning Activities

e With a friend or colleague, take it in turns to play with a range of small dolls and toy ani-
mals for 10 minutes while the other observes — then share thoughts and understandings
about how it felt to ‘just play, what was observed and what narratives/themes emerged.
e Reflect on three important figures in authority over you in your adult life - are there any
similarities in the way you see them or in the way you relate to them? If there are, think
about where these patterns might come from in your early life.
e With a friend or colleague, take it in turns to tell each other a story from your life, some-
thing important but not too powerful. The listener should concentrate not on what is
said but on how they themselves feel, both physically and emotionally. Then feed back
to each other and discuss.
® *%

Further Reading

Blake, P. (2011). Child and Adolescent Psychotherapy. London: Karnac.

French, L. and Klein, R. (2012) Therapeutic Practice in Schools. London: Routledge.
Kegerreis, S. (2010) Psychodynamic Counselling with Children and Young People: An Introduction.
London: Palgrave.
Lanyado, M. and Horne, A. (eds) (2009) The Handbook of Child and Adolescent Psychotherapy:
Psychoanalytic Approaches. 2nd edn. London: Routledge.
 Cognitive-Behavioural Therapy
Paul Stallard

This chapter includes:

e An historical overview of CBT and the underlying theoretical model

e The therapeutic process of CBT and phases of treatment
e How CBT is adapted for use with children and young people

Introduction

Although developed from work with adults, cognitive-behavioural therapy (CBT) can
be used with children from seven years of age if it is carefully adapted to the develop-
mental level of the child. With younger children CBT may need to be simpler, made
concrete through the use of familiar everyday metaphors and involve less verbal and
more visual techniques. Adolescents will have more developed cognitive and verbal
skills and may be able to engage in more sophisticated and abstract verbal discussions.
CBT provides an evidence-based approach to the treatment of emotional problems
in children and adolescents.

e It is based on the premise that psychological problems arise from dysfunctional and
unhelpful cognitions which are maintained by attention and memory biases, emotional
responses and maladaptive behaviours.
e Through the process of collaborative empiricism dysfunctional cognitions are subject
to objective evaluation through techniques such as Socratic dialogues and behavioural
experiments.
50 The Handbook of Counselling Children & Young People

® These result in the discovery of new or overlooked information and alternative meanings
about events, which leads to the development of more functional and balanced cognitions.
e Coping is enhanced through the development of emotional literacy and management
skills and performance through behavioural and problem-solving skills.
e Enhanced coping and performance results in greater reinforcement of positive and adap-
tive behaviours.

Historical Development

CBT was heavily influenced by the pioneering work of Albert Ellis (1994) and Aaron
Beck (1963, 1964) and their models of rational emotional therapy and cognitive ther-
apy. These models built upon the success of behaviour therapy by attending to the
meanings and interpretations individuals make about events. Initially CBT was devel-
oped for adults, and it was not until the 1990s that descriptions of the way CBT could
be used with children began to emerge (Kendall, 1991). Many early studies applied
CBT programmes developed for use with adults to older adolescents, and how these
were adapted for children received comparatively little attention. However, the new
millennium heralded the arrival of a number of publications that described how CBT
can be adapted for use with children (see Further Reading).
One of the first randomised controlled trials to evaluate the effectiveness of CBT with
adolescents was published in 1990 (Lewinsohn et al., 1990). The following 20 years saw
an explosion of empirical studies that have established CBT as the most extensively
researched of all the child psychotherapies (Graham, 2005). Early research compared
CBT to waitlist control groups and found large treatment effects. The next wave of trials
compared CBT with other active interventions and, unsurprisingly, treatment effect sizes
were smaller but nonetheless positive. For example, when CBT was compared with medi-
cation, CBT was not found to be superior, although the results confirmed that CBT offers
an effective psychological intervention (Goodyer et al., 2007; Treatment for Adolescents
with Depression Study (TADS) Team, 2009; Brent et al., 2008; Walkup et al., 2008).
Similarly, CBT programmes provided in schools as prevention or early interventions for
the treatment of anxiety or depression have demonstrated very positive results (Calear
and Christensen, 2010; Neil and Christensen, 2009; Mychailyszyn et al., 2012). This
extensive research has resulted in CBT being recommended by expert groups such as the
UK National Institute for Health and Clinical Excellence and the American Academy of
Child and Adolescent Psychiatry for the treatment of children with emotional disorders
including depression, obsessive compulsive disorders, post-traumatic stress disorder and
anxiety. This growing evidence base has also prompted the development of national train-
ing programmes in CBT and the extension of the UK Improving Access to Psychological
Therapies Programme to children and young people (IAPT, 2012).
 Cognitive-Behavioural
Therapy 51

Theoretical Model

CBT is concerned with the relationships between cognitive, emotional and behavioural
processes.
Behavioural theory is based on the premise that maladaptive behaviours are learned
and draws upon the principles of classical and operant conditioning. Classical con-
ditioning focuses upon the role of antecedent conditions in which neutral stimuli or
situations (e.g. a shop) become associated with an involuntary response (e.g. anxiety).
Interventions involve techniques such as learning relaxation skills to counter anxiety;
the development of a hierarchy of situations that elicit anxiety; graded exposure and
systematic desensitisation whereby anxiety is controlled whilst feared situations are
faced and mastered.
Operant conditioning focuses upon the role of consequences in maintaining mala-
daptive behaviours. It assumes that behaviours that are rewarded (positively reinforced)
or are followed by the removal of an aversive consequence (negative reinforcement) are
more likely to be repeated. For example, a child who is anxious about leaving the house
to go to school may be allowed to stay at home (i.e. staying at home is positively rein-
forced). If their anxiety is reduced by avoiding school, then school non-attendance is
negatively reinforced (i.e. avoidance reduces anxiety). In both cases the consequences
will result in the child being less likely to leave the house and go to school. Interventions
involve contingency management whereby adaptive behaviours are reinforced.
Whilst behaviour therapy is effective, it fails to consider the personal meanings
and interpretations that are made about the events that occur. Cognitive therapy
emerged to address this issue and is based on the premise that mental health prob-
lems arise when dysfunctional and biased meanings and interpretations are made.
The cognitive model proposed by Beck et al. (1979) suggests different levels of
cognitions with the deepest being schemas which are strong, global, fixed ways of
thinking that underpin the meanings and interpretations that are made. Schemas
can be functional and adaptive but some are overly rigid, negative and dysfunc-
tional. They are assumed to develop during childhood as a result of significant
and/or repeated experiences. Poor attachment, maltreatment or overly critical and
demanding parents may, for example, lead a child to develop a cognitive schema that
they are ‘unlovable’ or a ‘failure:
Schemas are activated by events reminiscent of those that produced the schema.
Once activated, attention, memory and interpretation processing biases filter and
select information that supports the schema. Attention biases result in attention being
focused upon information that confirms the schema whilst neutral or contradictory
information is overlooked. Memory biases result in the recall of information that is
consistent with the schema whilst interpretation biases serve to minimise any incon-
sistent information.
52 The Handbook of Counselling Children & Young People

The most accessible level of cognitions are automatic thoughts or ‘self-talk’ and
represent the involuntary stream of thoughts that run through the mind providing a
continuous commentary about events. These are functionally related to schemas, with
dysfunctional schemas producing negative automatic thoughts. Negative automatic
thoughts tend to be biased and self-critical and generate unpleasant emotional states,
e.g. anxiety, anger, unhappiness and maladaptive behaviours such as social withdrawal
or avoidance. The unpleasant feelings and maladaptive behaviours associated with
these dysfunctional cognitions and processing biases serve to reinforce and maintain
them as the individual becomes trapped in a self-perpetuating negative cycle, as high-
lighted in Figure 4.1.

Significant or repeated
negative childhood
experiences

Development of
Dysfunctional Cognitive
Schemas

Activated by Triggering

=
Events

Reinforce

Information Processing
Biases

Negative Automatic
Thoughts

Unpleasant emotional
and physiological
response

Maladaptive Behaviours

Figure 4.1 —Reinforcing behaviours.

In addition to the different levels of cognitions, CBT is concerned with the specific
content of dominant cognitions which vary according to the particular psychological
 Cognitive-Behavioural
Therapy 53

problem. Depression, for example, tends to be related to cognitions concerning loss,

deprivation and failure; anxiety to cognitions of personal threat, vulnerability and
inability to cope; obsessive compulsive disorder with cognitions of personal responsi-
bility for harm; PTSD with current threat and panic with catastrophic interpretations
of physiological symptoms.
The aim of CBT is to identify, test and reappraise dysfunctional and unhelpful cogni-
tions. Testing involves challenging selective attention biases by attending to overlooked
information, challenging memory biases by recalling contradictory experiences and
challenging interpretation biases by exploring alternative explanations. Two key methods
of achieving this are Socratic dialogues and behavioural experiments.
Socratic dialogues help to discover new information which questions or contradicts
the meanings or interpretations that are made. Attending to new or overlooked infor-
mation challenges internal, stable and global beliefs (e.g. I am stupid; no-one likes me)
and helps to develop functional cognitions by establishing limits (e.g. maths is hard but
Iam good at art; none of the people I know have the same interests as me).
Behavioural experiments provide an objective way of testing assumptions and beliefs.
A belief that ‘no one likes me’ could be tested by recording how many times a young
person receives a text, email, Facebook hit or phone call in a week. A prediction is made
at the start of the experiment about what will happen (e.g. no-one will contact me)
which is compared with the outcome. Through this process limits are placed around
global schemas, which helps to promote more balanced and functional cognitions.

Therapeutic Process

CBT occurs within the context of a strong therapeutic relationship. The relationship
needs to be open, honest and non-judgemental and is conveyed through a genuine,
warm and respectful rapport. The process is one of collaborative empiricism in which
the therapist and child actively work together to test the child’s beliefs and interpreta-
tions. Stallard (2005) has defined the key elements of this process with children by the
acronym PRECISE.

e P: highlights the need to develop a therapeutic partnership based upon collaborative

empiricism and emphasises the central role of the child and their parents/carers in secur-
ing change.
e R: draws the therapist's attention to developmental considerations and the need to
ensure that the intervention is right for the child’s cognitive, linguistic, memory and per-
spective-taking abilities.
e E:highlights the need to develop and maintain an empathic relationship which conveys
warmth, genuine concern and respect.
54 The Handbook of Counselling Children & Young People

e C:identifies the need to be appropriately creative in conveying the concepts of CBT in

ways that match the child’s developmental understanding and interests.
e |: highlights investigation and the need to adopt a curious, open and inquisitive stance
in which thoughts are subject to objective evaluation through Socratic dialogues and
behavioural experiments.
e 5S: encourages the development of self-efficacy and learning through reflection and
assimilation of new information.
e E:highlights the importance of engagement and enjoyment and the need to ensure that
the child’s interests and motivation can be maintained.

Phases of CBT

CBT typically involves the four phases of psycho-education and relationship building,
skills development, consolidation and relapse prevention.

Psycho-Education and Relationship Building

During this initial phase, the primary focus is upon engagement, developing the thera-
peutic partnership and socialising the child and their family into the cognitive model.
Information is provided about the cognitive model (the link between events, thoughts,
feelings and behaviours) and an overview of what therapy will involve. The idea of
learning together (collaborative empiricism) and the active role of the child in test-
ing ideas and undertaking experiments is emphasised. A shared understanding of the
child’s problem within a CBT framework (a cognitive formulation) is jointly developed
and treatment goals are identified.
The therapist has a fairly active role during this stage as they provide information and
develop the therapeutic alliance. This is a key task since typically children are referred
because of concerns from others, and they may have no ownership of the referred prob-
lem or little motivation to change. Engaging and motivating the child is a prerequisite
to the subsequent stages of CBT. The therapist therefore presents as open, understand-
ing, positive and hopeful as they elicit commitment from the child to ‘give it a try.

Skills Development

The second phase focuses upon the development of skills to counter dysfunctional
cognitions and processing, unpleasant emotional states and maladaptive behaviours.
 Cognitive-Behavioural
Therapy 55

The particular skills and domains of the intervention will be informed by the formu-
lation. In the cognitive domain, cognitive enhancement will help the child assess the
accuracy and usefulness of their cognitions and to develop more helpful, balanced
cognitions. Different types of cognitions (helpful and unhelpful thoughts), process-
ing biases (thinking traps) and common dysfunctional cognitions will be identified
through thought monitoring. Behavioural experiments and Socratic dialogues will be
used to systematically test these unhelpful cognitions and processes in order to identify
new or overlooked information. This process results in limits being placed around dys-
functional global beliefs and negative thoughts and provides alternative interpretations
which are more balanced and functional.
Emotional skills may be enhanced to promote better understanding, awareness and
management of unpleasant emotions. Emotional monitoring can help to identify links
between emotions, events and thoughts and those situations that are associated with
particularly strong, unpleasant or prolonged emotional states. Emotional management
may be developed through relaxation training, positive imagery or activity reschedul-
ing to reduce the intensity or frequency of unpleasant emotions.
In terms of behaviour, the intervention may involve developing more adaptive
behaviours in which problem-solving and social and personal effectiveness skills such
as assertion and negotiation are enhanced. This may involve techniques such as role-
play, observational exercises, graded exposure, behavioural activation or response
prevention. Finally, the child is encouraged to notice and reinforce positive attempts
to change.
During the skills development phase the therapist adopts an open and curious
approach to encourage the child to experiment and discover skills and strategies that
are particularly helpful for them.

Consolidation

The third stage is consolidation, where the new skills are practised and integrated into
the child’s everyday repertoire. By this stage the child has a good understanding of the
key elements of the cognitive model, their key cognitions and thinking traps. Regular
practice of session assignments is a particularly important aspect of CBT at this stage.
Through these assignments the child is encouraged to systematically face and cope
with increasingly difficult situations and problems as they use their new skills to regain
control of their life.
The therapist becomes more reflective as the child is increasingly encouraged to take
a lead role in analysing difficult situations and finding solutions. The therapist reminds
the child of the core elements of the CBT model and the skills they have acquired and
encourages them to apply this framework and these skills.
56 The Handbook of Counselling Children & Young People

Relapse Prevention

The final stage is relapse prevention where the child is encouraged to reflect on those
aspects of the intervention that have been most helpful, prepare for possible relapse and
to develop a contingency plan in case problems re-emerge. Their own specific thinking
traps are highlighted and the skills and techniques that have helped to challenge dysfunc-
tional internal, stable and global cognitions identified. The child is prepared for relapse
and a plan developed to deal with short-term problems, and triggers for seeking further
help are identified. During the final phase the therapist is a facilitator who encourages
the child to process their learning and apply it to future situations and events.

Adapting CBT for Children

CBT was originally developed for work with adults. It relies heavily on verbal and
memory skills and involves advanced meta-cognitive skills which require individuals
to be both aware of their cognitions and able to reflect upon them. Through this pro-
cess the individual is helped to find overlooked information and new meanings, which
lead to the development of alternative, more functional cognitions.
Childhood and adolescence are characterised by significant and rapid development
of cognitive, linguistic and memory skills. It is generally recognised that children from
seven years of age can engage in CBT, although the content and process will need to be
adapted to reflect their developmental level. Younger children, for example, may have
problems with some cognitive tasks such as identifying and appraising cognitions. This
does not necessarily imply that they cannot engage in CBT but indicates that some
preparatory psycho-educational work may be required to help them identify and find
ways to communicate their cognitions. This may involve use of worksheets where the
child is given a picture with a single thought bubble (e.g. footballer preparing to take
a penalty) and asked to identify what the person may be thinking. Extra thought bubbles
can be added to introduce the child to the notion of alternative thinking, ie. there
may be different thoughts about the same situation (for example, a picture of someone
receiving a present, with two or three thought bubbles).
Whilst younger children can typically generate some cognitions, they may not neces-
sarily be able to understand general or overarching cognitive patterns, their cognitive
processes or generalise dysfunctional patterns from one situation to another. The ther-
apist may need to be more focused and use the cognitive framework to increase their
understanding of specific events or difficulties.
Young children may also find the process of cognitive appraisal difficult, although
they can be helped to engage with this if provided with a clear framework. They could
be encouraged to become detectives and to actively seek ‘evidence’ for and against their
 Cognitive-Behavioural Therapy 57

way of thinking. Once the evidence has been collected the child can be encouraged to
‘weigh it up’ and to decide how well their thinking fits the evidence. Phrases such as
‘catch it, check it, change it’ can be helpful. This reminds the child to ‘catch their com-
mon dysfunctional thoughts and to ‘check’ them to see if they make them feel good
and help them to face challenges. If not, the final step is to ‘change’ them into more
functional and activating thoughts that make them feel good.
Metaphors can be a helpful way of relating abstract concepts to familiar, everyday
situations. A washing machine can be used to explain the way some thoughts tumble
around and around in our heads. ‘Computer spam; ‘thought invaders’ or the metaphor of a
CD playing in one’s head can be used to explain automatic thoughts and how they just pop
up without being requested and are difficult to ignore. These can be developed into coping
strategies. For example, children could be encouraged to develop a computer firewall and
shoot down their invading thoughts or to turn the volume down on the CD so they can
stop listening to their negative thoughts. The metaphor of an anger volcano can help chil-
dren understand the cognitive and emotional build-up that occurs before they lose their
temper. Once the stages have been mapped, strategies can be developed to stop the volcano
from blowing. Finally, a metaphor of traffic lights can be used to discuss dysfunctional and
functional thoughts and how they affect our behaviour. Red (dysfunctional) thoughts stop
us from doing things whilst green (functional) thoughts are empowering and activating.
Adolescents have more developed cognitive abilities and often enjoy the debate of
the Socratic dialogue. Most are able to identify, test and challenge their cognitions and
many are able to engage in more complex cognitive work in which common themes
and processes are identified. It is not, however, uncommon to find that adolescents
hold very strong beliefs and are unable to see alternative explanations. This can result
in the therapist becoming increasingly active in generating alternative views which are
simply dismissed by the adolescent as the Socratic dialogue becomes lost. It is therefore
important that the therapist remains open, non-judgemental and curious and main-
tains an objective focus to help the adolescent reflect upon and question their beliefs.

Non-Verbal Methods

CBT with children also requires greater use of non-verbal methods. Drawings can be
helpful and provide a useful way of externalising problems and separating them from
the child. For example, children with OCD can be encouraged to draw and give a name
to their OCD which they can then learn to boss back. Games such as emotional charades
can be used to act out different emotions to help children identify facial expressions
associated with different emotions. Brightly coloured worksheets provide engaging ways
to help children map physiological changes associated with different emotions onto out-
line body shapes. The development of a feelings scrapbook can be a fun way for young
children to establish a library of pictures expressing different emotions.
 58 The Handbook of Counselling Children & Young People

Puppets can provide an engaging way to help young children talk about their
worrying thoughts and feelings. Problem situations can be acted out and children
encouraged to suggest what the puppets might be thinking in order to identify
potentially important cognitions. They can also be used to develop skills by encouraging
children to coach their puppet through a difficult situation
With adolescents a greater use of technology can be helpful. Video or YouTube clips
can provide a visual introduction to many of the key areas of CBT and can be used to
introduce, highlight or facilitate discussions. Computer logs can be used as methods of
self-monitoring and email as a way of reminding young people about out-of-session
assignments and for providing feedback. The internet provides a rich source of informa-
tion which individuals can be encouraged to use to seek evidence that might challenge
their beliefs, e.g. fears about contamination or transmission of disease. Pie charts provide
useful visual ways of challenging and reappraising beliefs about responsibility or blame.
Similarly, quizzes can help young people identify different types of thinking traps.
Finally, visual diagrams depicting a problem formulation or the link between events,
thoughts, feelings and behaviours can provide helpful ways of reinforcing the cogni-
tive model. Printed material can supplement the session and provide a fuller and more
accurate record of discussions and key points, while visual rating scales help to quantify
belief in thoughts or strength of feelings and provide a useful way of demonstrating
change over time.

i ite
Case Study Sarah
Sarah, 13, was referred by her GP with severe anxiety. She had a long history of anxiety but this was
increasingly interfering with everyday life to the extent that she was now reluctant to go out and was
experiencing panic attacks.

Psycho-Education and Relationship Building

The first assessment session was with Sarah and her mother. Sarah presented as bright, articulate,
readily engaged with the meeting and appeared very motivated to control her anxiety.
The second session completed the assessment with information from standardised anxiety meas-
ures complementing the clinical interview. This confirmed that Sarah had a generalised anxiety
problem that was resulting in panic attacks in public. At the end of the session Sarah agreed to com-
plete a mood diary and to record any times she became anxious
The diary was reviewed in session three and identified three anxious situations. All occurred when
Sarah was invited out (to the cinema, to sleep at a friend’s, shopping) and resulted in her being
unable to go. This information was used to map a formulation which highlighted the connection
 Cognitive-Behavioural
Therapy 59

=
between her thoughts (‘I won't be able to cope’) with her emotions (anxiety) and behaviour (avoid
leaving home). Finally, the process of CBT was discussed and how the therapist would help Sarah to
discover ways to manage her anxious feelings. Sarah agreed to complete another diary describing
the bodily signals she noticed when she became anxious.

Skills Development
The fourth session focused upon emotional recognition. The physiological anxiety reaction was
explained and the signals that Sarah recorded in her diary were discussed (racing heart, difficulty
breathing, hot and sweating). Sarah was then asked to record any thoughts she noticed when she
became anxious and what she did.
Session five focused upon the development of anxiety management skills. A number of anxiety
management skills were identified and potentially useful ideas practised. In particular controlled
breathing, listening to music and visualising a relaxation place were identified as potentially useful.
Sarah agreed to practise these methods at home each day and agreed to record her thoughts when
she became anxious.
The diary was reviewed in session six. Controlled breathing was helpful when Sarah began to feel
anxious, whilst listening to music and visualisation helped her to prepare for potentially worrying
situations. There was one situation when Sarah was invited shopping but was unable to control her
anxiety. She recorded her thoughts (‘I will become anxious and won't be able to cope’;‘Ilalways panic
when | go shopping’;‘Iwill make a fool of myself’). This led to an exploration of processing biases and
how Sarah had fallen into the ‘fortune teller’ thinking trap where she was predicting failure. Sarah
agreed to keep the diary for another week.
In session seven Sarah reported that she had gone to the school dance. She had become anxious
before she went (‘I look awful in this dress’) but successfully managed this with her visualisation.
However, whilst at the dance she was constantly looking for signs that she did not look nice. The
‘negative glasses’ thinking trap was discussed and a Socratic dialogue used to help Sarah find infor-
mation that she had overlooked (e.g. comments from her best friends; postings on Facebook). This
provided a direct challenge to Sarah’s thoughts and helped her to recognise that others thought
‘she looked nice’. This event also challenged Sarah’s belief that she was not safe and unable to cope
when she was out. The session ended with Sarah agreeing to develop a list of activities that she
would like to do.

Consolidation

In session eight Sarah was encouraged to use her skills to cope with challenging situations. The
activity that Sarah felt would be the easiest to manage was to go with her best friend to the local
coffee shop. Sarah was asked what she thought would happen (have a panic attack) and she rated
her belief that she wouldn't be able to cope (80/100). A behavioural experiment was agreed to
test her belief. Helpful skills were rehearsed: relaxing visualisation before she went and controlled
(Continued)
 60 The Handbook of Counselling Children & Young People

(Continued) ne

breathing if she felt anxious whilst out. Functional cognitions were practised (‘I have done this
before so | can only give it a go and see what happens’) and a way of countering her thinking trap
(negative glasses) by focusing upon what she was achieving rather than what she felt she could do
better was rehearsed.
Session nine revealed that Sarah had successfully been to the coffee shop with her friend. She did
not become unduly anxious and rated the belief that she wasn’t able to cope as 40/100. Over the
next three sessions further experiments were agreed, culminating in Sarah going out one Saturday
shopping with her friends.

Relapse Prevention
The final sessions were monthly and encouraged Sarah to reflect on what she had discovered and
the skills she found useful. Possible setbacks were discussed and a written coping plan developed.
She continued to face and cope with increasingly difficult situations, and six weeks after the final
appointment she sent a postcard from London where she had gone shopping with her friends.
oe

Summary

This chapter has focused on:

e Historical development of CBT

e Theoretical model
e Therapeutic process
e Phases of CBT
e Adapting CBT for children
e Non-verbal methods

Reflective Questions

1 How might you incorporate more non-verbal techniques into

your practice?

Younger children: cartoons and thought bubbles can be used to identify and discuss what
someone might be thinking; pictures and worksheets can stimulate and emphasise key
 Cognitive-Behavioural
Therapy 61

aspects of the CBT model; games like emotional charades can highlight the different
facial and bodily signals associated with different emotions. Older children: diagrams
and summary sheets (explaining the link between thoughts, feelings and behaviours)
provide a useful way of summarising the cognitive model; video clips can be a useful way
of presenting ideas and stimulating discussions (e.g. around thinking styles and errors).

2 When you ask a child or young person ‘what were you thinking?’
they reply ‘nothing’ or ‘I don’t know’. Does this mean that they
are not able to engage in CBT?

It is not uncommon for young people to reply to direct questions in such a way. This
does not mean that they are unable to identify their thoughts but suggests that alterna-
tive methods might be more productive. You can help them tune into their thoughts by
talking about positive or familiar events (e.g. preparing for something they like) or by
talking about what a third party could be thinking. With younger children you could
describe an event and ask them to write or draw a picture in a blank thought bubble
to show what someone might be thinking about it. Alternatively, you may discover a
child’s thoughts by simply listening very carefully to what they say. Descriptions often
include thoughts and assumptions which we are not always very good at noticing.

3 What tends to be the content of negative automatic thoughts

associated with anxiety and depression?

The content of anxious cognitions tends to be about threat (‘people are looking at me’),
danger (‘everyone will make fun of my new trainers’) or an inability to cope (‘I wont
know what to say if they ask me any questions’). Depressive cognitions tend to be about
loss (‘everyone I get to know leaves me’), deprivation (‘I am sure I'm not as interesting
as everyone else’) and failure (‘I am useless at talking to people’).

4 What are the key characteristics of functional and dysfunctional

thoughts?

Functional thoughts can be described as ‘green thoughts’ because they are motivating
and encourage you to do things. They are positive (‘I can do it’), balanced (‘this might
be hard but I have done it before’) and enabling (‘I’ve got nothing to lose by giving it
a try’). Dysfunctional thoughts are ‘red thoughts’ which stop you from doing things.
62 The Handbook of Counselling Children & Young People

They are negative (‘I will get this wrong’), biased (‘I can never get this right’) and are
disempowering (‘there is no point in trying’).

an me ee, A, | ne! ee a a a a eS et ae beak oe

*
Learning Activities

1 How would you explain CBT to a 9- or 10-year-old child with an anxiety disorder?

Keep the explanation very simple. You could say that ‘people who worry often think in ways
that make them feel frightened. When they feel frightened they want to avoid the things
that scare them. We will work together to see if this happens for you by looking at the way
you think, how you feel and what you do’

2 You would like to find out more about the negative thoughts a 14-year-old boy is having
and think that a thought diary would be helpful. How would you go about doing this?

You would need to provide a rationale and explain why this was important and negotiate
whether he would be able to undertake this task. The ‘diary’ could be a paper record, computer
log, text or email so the boy can choose a method that he finds most attractive. Check that
the diary is achievable, e.g. you may agree to record a whole week or the next three negative
thoughts. If the boy feels unable to keep the diary then respect his decision.
You will still be able
to find out about his thoughts by talking through any situations during your next meeting.

3 Design an experiment to test a belief that ‘I never get my school work right’

Ask the young person to predict what they think would happen ifthis was true, i.e. | will get
D grades or lower. Ask them to rate how much they believed this thought on a 1-100 scale.
The young person could then record all their school marks over the next week. What actu-
ally happened is then compared with what they predicted, to test their belief. How much
they believed the original thought can then be re-assessed to see whether the experiment
had helped them discover any new information which challenged their original belief (e.g.
‘!seem to get better marks in history’).

4 Think about some Socratic questions you could use with adolescents

Socratic questions are designed to encourage self-refection with the aim of helping the
young person find new information and meanings which challenge their existing thoughts.
The therapist adopts an open and curious stance and uses questions to draw the young
person's attention to exceptions (‘have there been any times that this didn’t happen?’), reflect
on different perspectives (‘what would your best friend think if this happened to them?’) and
to consider different meanings (‘are there any other explanations for what has happened?’).
®
 Cognitive-Behavioural
Therapy 63

Further Reading

Adapting CBT

Friedberg, R.D. and McClure, J.M. (2002) Clinical Practice of Cognitive Therapy with Children and
Adolescents. New York: Guilford Press.
Friedberg, R.D., McClure, J.M. and Hillwig Garcia, J. (2009) Cognitive Therapy Techniques for Children
and Adolescents. New York: Guilford Press.
Kendall, P.C. (ed.) (2012) Child and Adolescent Therapy: Cognitive-Behavioral Procedures. 4th edn.
New York: Guilford Press.
Stallard, P. (2002) Think Good — Feel Good: A Cognitive Behaviour Therapy Workbook for Children and
Young People. Chichester: John Wiley.
Stallard, P. (2005) A Clinician’s Guide to Think Good — Feel Good: The Use of CBT with Children and
Young People. Chichester: John Wiley.
Verduyn, C., Rogers, J. and Woods, A. (2009) Depression: Cognitive Behaviour Therapy with Children
and Young People. London: Routledge.

Examples of CBT Programmes

Barrett, P. (2012) Friends for Life: Group Leaders Manual. 5th edn. Available at: www.friendsinfo.net/
uk.htm (FRIENDS anxiety prevention programme).
Clarke, G., Lewinsohn, P., Hops, H. and Grossen, B. (1990) Leader’s Manual for Adolescent Groups.
Available at: www.kpchr.org/research/public/acwd/acwd.html (Adolescent coping with
depression course).
Kendall, PC. and Hedtke, K.A. (2006) Cognitive Behavioural Therapy for Anxious Children: Therapist
Manual. 3rd edn. Available at: www.workbookpublishing.com/ (Coping Cat anxiety treatment
programme).
TADS CBT
Rohde, P.,, Feeny, N.C. and Robins, M. (2005) Characteristics and Components of the
used
Approach. Available at: www.ncbi.nIm.nih.gov/pmc/articles/PMC1894655/ (Programme
in the Treatment for Adolescents with Depression Study — TADS).
 Gestalt
Belinda Harris

This chapter includes:

Key gestalt concepts and relational processes that inform a gestalt understanding of human
development
The research evidence for gestalt practice with children and young people
The development of gestalt theory, and significant influences on its formulation and evolution
Key features of and relational processes involved in gestalt practice, illustrated by thickly dis-
guised case vignettes
Gestalt as a brief therapy

Introduction

As a humanistic teacher and counsellor working with adolescents in schools in chal-

lenging circumstances, I was drawn to gestalt because of familiarity with its underlying
philosophical approach, including a focus on the whole person (holism), on awareness
of immediate, present-centred experience (existential-humanism), and on the way the
individual perceives and engages with reality (phenomenology). Gestalt’s particular
appeal, however, lay in the emphasis placed on the young person in their situation, its
field theoretical orientation.
 Gestalt 65

Field Theory and the Evolution of Self

The concept of field has two meanings here: the first focuses on the way the person
organises their inner experience (perceptual field) to make meaning of their situation;
the second (derived from Lewin’s (1935) field theory) recognises that the person and
their world are inseparable and interdependent parts of a dynamic whole, or gestalt.
Gestalt recognises human development as a lifelong, co-creative and inter-subjective
process. The self-experience of the infant and the self-experience of the parent there-
fore co-evolve within a dynamically unfolding relational field. It is the present moment
experience (sensory, physical, emotional and cognitive) between adult and child that
enables the child to differentiate between the T and the “not I’, and the adult to develop
their felt sense as a parent (e.g. competent or incompetent) in relation to the child.
This energetic meeting at the contact boundary (Goodman, 1951) leads to an itera-
tive, vibrant integration of experience; a perspective that is consistent with Stern's infant
observation research (1985), and with recent findings in affective neuroscience (Lee,
2007). The gestalt therapist’s focus, therefore, is on the young client within their situa-
tion, and may involve working with members of the child’s relational field to enhance
their ability to support the child.

The Relational Field

The relational field has two elements:

a) the ground of the relationship, which includes, for example, the child’s unique character-
istics (e.g. health, temperament, etc.) and the parents’ mental model of parenting, values
and support systems;
b) the figure - the dominant need informing the relational contact (e.g. the child is tired and
needs to be carried).

These elements combine in the embodied, present-centred experience of child and

adult at the contact boundary, as each makes a ‘creative adjustment’ (Goodman, 1951)
to the other. If the need is met and assimilated, the gestalt is closed and a state of bal-
ance is restored (i.e. the child is rested and re-energised). McConville (2007) argues
that two ground conditions are particularly important in supporting child develop-
ment, namely the extent and ways in which power is exercised to influence the child's
choices and behaviours, and the way the boundaries of the relationship are organised
and transformed over time to meet the child’s emergent developmental needs.
66 The Handbook of Counselling Children & Young People

When the use of power and boundaries is sufficiently attuned to the needs and
capabilities of the child and the here-and-now situation, then the child's organismic
self-regulation process (Perls, 1948: 576) is activated and their evolving sense of self
is supported. For example, when a toddler moves towards danger (e.g. an electrical
socket), the parent acts decisively but gently to divert their attention elsewhere. Such
contact alters the ground of the child—adult relationship and the toddler trusts the rela-
tional field to meet their need for safe, self-environment exploration.
Conversely, if the toddler’s needs for safety and containment are ignored or responded
to with harshness or contempt, then the flow of their experiencing is interrupted. Where
neglect or abuse persists, the creative adjustment needed to manage and make meaning
of the situation is likely to result in a fixed gestalt, or rigid way of being at the contact
boundary when similar situations occur. This is evident, for example, when a distraught,
sobbing boy is scornfully told to ‘stop being a sissy and act like a man. If repeated over
time, he learns not to approach another for support when he is distressed, then he learns
to stop himself from crying, and eventually he becomes unaware of his need to cry when
he is hurting. A fixed gestalt therefore is often indicative of an unfinished situation.

Unfinished Situations

Perls (1969 [1947]) identified a physiological-biological ‘cycle of interdependency of

organism and environment’ (p. 45) which Goodman (1951) subsequently categorised as
fore-contact, contact, final contact and post-contact. If followed sequentially, these stages of
contact between the child and others in their environment enable them to create a mean-
ingful whole (gestalt) from their experience. The sense of completion and closure of the
gestalting process is experienced intuitively as ‘right, and is accompanied by a sense of calm,
satisfaction, peace or fulfilment. However, if progression through the cycle is thwarted in
some way, and the gestalt remains incomplete, then unfinished business results.
The therapeutic relationship provides a here-and-now situation in which closure
(Perls, 1975 [1959]) can be experienced viscerally and emotionally. For example, a child
whose parents are over-protective may need support to define and express their own
needs and wants. The parents may also need help with unfinished situations (e.g. trau-
matic experience in childhood) to manage their hyper-anxiety about safety and reduce
the power they exert over the child’s choices within the relational field.

The Relational Field of Childhood

In early childhood the child’s primary need is for ‘embedding’ (McConville, 1995),
a sense of connection where they feel safe and protected enough to explore the
 Gestalt 67

environment, to express themselves physically and emotionally, and to trust in oth-

ers for stimulation, comfort and support. During the embedding phase the child
needs a ‘porous relational boundary’ (McConville, 2007: 9) where significant adults
are intensely involved with the child’s physical growth and well-being. Adults use
their power to soothe and support the child’s affective experiencing, as well as to
firmly and decisively inhibit behaviours that could do harm, and refuse to accede
to the child’s excessive or inappropriate wants. In other words, the child experiences
support whilst also learning to manage their emotions (fear, sadness, anger, joy) and
tolerate disappointment.

The Relational Field of Adolescence

In contrast, the adolescent is focused on the process of ‘disembedding’ (McConville,

1995) from the family and other adult systems of support. This involves a major reor-
ganisation of the field, based on differentiation of self from others and integration of
the evolving self into new Gestalten or wholes. The adolescent is actively involved in
stretching and redefining their power and boundaries, and needs significant adults
(and their therapist) to support a ‘safe emergency’ (Perls et al., 1951) of the adult self,
and of their worlds, whether family, social, or educational. ‘Safe emergency, a term
coined by Perls et al. (1951), highlights the importance of just enough support to risk
experimenting with new behaviours, in service of ‘becoming’ whole.
McConville (2007) highlights the key role of negotiation in this process, so that adult
and adolescent meet at the contact boundary as separate individuals. Here they discuss
what actions are reasonable and acceptable according to the adolescent's immediate
wishes, and in the context of the environmental situation. Handled well, such negotia-
tions are characterised by and nourish mutual respect and a flexible, rather than rigid,
responsiveness. The adolescent is held accountable for their behaviours and there is a
positive shift in the ground of the child-adult relationship, whereby the adolescent dis-
embeds from the family without losing their sense of belonging, and the family slowly
adjusts to and appreciates the emerging adult without a loss of connection to their child
or sibling.

The Shame-—Support Dynamic

The reader may have noticed the frequent use of the word ‘support, and gestalt thera-
pists are curious about the quality and quantity of support in the person-environment
field. Where, for example, the demands of the environment and the needs of the child
conflict, then the creative adjustment required of the child and/or the environment
68 The Handbook of Counselling Children & Young People

to accommodate the other may be costly. For example, for children and young people
with complex trauma, the behaviours required of them in school settings constitute a
‘big ask’ (Bomber, 2011), and without sufficient support the student is likely to fail in
some way and experience further punishment, rejection and humiliation.
From a gestalt perspective such situations manifest as shame, which is ‘a major
regulator of the boundary between self and other. It is a field variable, a ground condi-
tion that is the opposite of support’ (Lee, 1996: 10; emphasis in original). Shame is an
excruciating sense of self-disgust and isolation, in which the individual's yearnings for
connection are unmet. This creates a ‘shame bind’ (Kaufman, 1989), whereby the indi-
vidual withdraws from the environment rather than reaching out. This is often as true
of parents, who feel judged and blamed for their child’s misdemeanours, and therefore
avoid contact with the school. The shame bind not only inhibits the awareness and
expression of vital, positive energy but also creates strong neural pathways for experi-
encing self-disgust and rejection in early childhood (Philippson, 2004).
In this situation the therapeutic process involves novel experiences that foster
the development of new neural pathways. A gestalt therapist develops an in-depth
appreciation of shame dynamics and uses the relational field within and beyond the
therapy room to support the young client’s connection with self and others. Such
long-term work requires a therapist who has enough self-support to lean into the
shame — experiencing the client’s resistance to being accepted and to stay present
at the contact boundary. Despite being repeatedly mistrusted, verbally attacked and
rejected, the therapist remains solidly present until there is ‘at least a thread of a
relationship’ (Oaklander, 2006: 20), when the therapeutic work can begin.

History and Background of the Gestalt Approach

The early 20th century saw major developments in science and technology and a rise in
radical socialist movements, challenging the prevailing order. New movements in the
arts also challenged bourgeois values and norms, as evidenced by expressionist paint-
ings depicting the subjective feelings and fantasies of the artist. The founders of gestalt
therapy embraced the creativity, spontaneity and intuition of expressionism alongside
the existential focus on ‘being’ (what is) and ‘potential being, which is experienced
through the exercise of choice with self-responsibility.
Fritz Perls is considered the father of gestalt therapy, yet his two co-founders, Laura
Perls (dancer and philosopher) and Paul Goodman (radical thinker, activist and writer),
were significant contributors to its evolution. The Perls were trained as Freudian analysts
(Wulff, 1966) and critiqued Freud for refusing to evolve his theory further in the light
of new influences and information. In contrast, the founders eschewed dogmatism in
 Gestalt 69

favour of ‘the experimental, insecure, but creative, pioneering attitude (Perls, 1948: 586).
The Perls broke their ties with psychoanalysis (Perls, 1969 [1947]), and having escaped
German fascism, settled in New York in 1946, joining with Goodman to develop their
theory of gestalt practice. For this, they drew on direct experiences of working with key
professionals over previous decades.
Of particular relevance for this chapter are the influences of Martin Buber, Laura
Perls’ teacher; the neuropsychologist Kurt Goldstein, in whose clinic for soldiers with
traumatic brain injuries Perls worked (Goldstein identified the concept and process of
self-actualisation two decades before Abraham Maslow popularised it); Jacob Moreno,
who emphasised the client ‘showing’ and experiencing rather than talking ‘about’; and
Wilhelm Reich, whose breath- and body-oriented approach illuminated the processes
of working holistically.
Violet Oaklander is responsible for developing a comprehensive account of gestalt
therapeutic process with children. Originally trained as a teacher, in the 1960s she
found her niche with emotionally disturbed children. In childhood Oaklander expe-
rienced long-term hospitalisation and major surgical interventions. As a parent she
was further traumatised when one of her children was diagnosed with terminal lupus.
While he was dying in hospital, she attended a one week gestalt group experience,
which she described as life changing (Elsbree, 2009). She attributed this impact to the
quality of the relationship with the group therapist, Jim Simkin:

He got me working on my grief, on my anger, on my avoidance ... my denial of what was

happening ... everything, but at the same time he was always with me. Talk about an ‘I-
Thou’ relationship, he was with me. ... He really got me working. When | say it changed
my life, |mean it somehow transformed me. (p. 205)

Oaklander then trained as a gestalt therapist and began to present and write up her
work. Windows to Our Children (1988) was adapted from her doctoral thesis, and
has been translated into 13 languages. Her experience with Simkin and other gestalt
trainers, including Laura Perls, who she described as a ‘loving presence, informed her
understanding of therapeutic process, which is characterised by contact, awareness and
dialogue on the bedrock of a safe, trustworthy, engaged relationship.
Whilst Oaklander still dominates the field, other gestalt therapists continue to evolve
the theory and practice of gestalt (e.g. Harris, 2011; Wheeler and McConville, 2002), to
acknowledge and incorporate the neuroscientific evidence, that affirms gestalt’s origi-
nal emphasis on the embodied (e.g. Tervo, 2007) and relational fields (e.g. Lee and
Harris, 2011) with reference to a range of presenting issues (e.g. eating disorders, sexu-
ality, grief, trauma, learning disabilities) and age groups (e.g. Blend, 2007; Blom, 2006).
In the next section I will illuminate the theory—practice relationship with reference to
case vignettes from practice.
 70 The Handbook of Counselling Children & Young People

Translating Theory into Practice

The Person of the Therapist

Perls (1970: 15) recognised that talking about issues inhibits awareness and that it is
sensory, embodied experiencing within the therapeutic relationship that opens the
door to change. Using their awareness as a searchlight, the gestalt therapist endeavours
to tune into the field, noticing their own experiencing (e.g. sensation, physicality, feel-
ings, fantasies) and moment by moment changes in the client’s contact (e.g. skin tone,
eye contact, posture, breathing, emotional expression), to be fully present to what is.

Case Study Meera

caus aan
Meera is eight years of age, and | notice my throat and chest tighten as she looks vacantly round the
room, before choosing to sit on a beanbag. Her breathing is shallow and her chest looks collapsed, as
if defeated. | sense that she needs me close, so | softly offer her the choice ‘Do you want me to
join you
or sit over here?’ She shrugs her shoulders, and yet moves over to create space, so | sit down alongside
her. We are quiet and there is a sense of calm between us. After a few minutes like this, she turns to
look up at me and quietly says Jodie, my dog, died’ | notice my throat and chest relaxing, and tears
welling up behind my eyes. She swallows hard and her chest tightens, so | gently offer, ‘It’s ok to cry
when someone you love dies; and she bursts into tears.
eee
This deliberate use of the embodied self is predicated on self-awareness, and gestalt
training is an intensive experiential process supported by ongoing in-depth personal
therapy. The trainee becomes acutely aware of their own embodied presence and impact
on others. Therapy requires humility and awareness that within the co-emerging field
anything can happen. There is no room for complacency or grandiosity.
Creativity lies at the heart of gestalt practice and the therapist must be imaginative
and comfortable playing in an uninhibited way with children and young people at all
developmental levels. Within the creative play the therapist is a willing participant in
the individual's efforts to define themselves, express their emotions, and gain some
sense of their potency and efficacy.
Oaklander (2006) describes vividly participating in games where she was bossed
about, handcuffed or tied up by young clients who needed an embodied experience of
feeling powerful and in control. I have certainly played the cowering pupil of a sham-
ing, angry 11-year-old teacher, in the service of completing an unfinished situation.
In this process clear limits and boundaries are vital, as is modelling ‘No’ appropriately.
 Gestalt 71

Rigorous attention to self-care, self-support and use of supervision are essential when
the therapist is committed to supporting the young client within their field. Working
with children and adolescents requires stamina and emotional resilience.

The Nature of the Relationship

For many young people, the therapist is just another adult who will let them down.
Therefore, being met at the contact boundary in a new way enables the client to re-sensitise
their awareness of the now, and of the totality of their experiencing, e.g. their likes and dis-
likes, their similarity to and difference from the therapist. Such awareness helps the young
person to define themselves and develop self-support, and is built on solid ground.

Establishing the Ground of the Relationship

Oaklander (2006: 27) compares therapy with children to a dance - ‘sometimes I lead and
sometimes the child leads: There is movement between directivity and non-directivity
according to the demands of the situation. In the early stages of the relationship the
focus is on safety and trust-building through the dialogic I-Thow’ relationship (Buber,
1959 [1937]). Here the therapist's authenticity and equanimity meet the child where they
are, as an equal and separate individual.
Through their embodied presence and ability to honour and respect the client's
resistance, contact style, rhythm and pace, they lay foundations for the work. They are
not interested in creating dependency or being a surrogate parent, but commit to being
a caring, supportive presence, holding an attitude of ‘creative indifference’ (Friedlander,
1918), or neutrality. This attitude supports ‘responding’ (Parlett, 2000), whereby the
client develops response-ability and responsibility for their choices through a gradual
expansion of experiences they can assimilate.

C ase Study Syed

Syed, aged 12, was referred for therapy by his teacher because of his constant distracting of others
and inability to sit still. Initially | copied his running and darting around the room, and voiced my
experience out loud, e.g. ‘I’m enjoying this pace’; ‘I’m hot and stopping for a moment’ Each week
the amount of time we spent in this cat and mouse game gradually decreased and he slowed down,
iei interested in exploring other games we could play together.
72 The Handbook of Counselling Children & Young People

Developing the Client’s Sense of Self

Once the relationship is established, then we work together to develop the child's
‘embodying’ ability (Parlett, 2000), including awareness of their senses, their breath-
ing, the way they use their body and express their thoughts and feelings. In all this
the therapist is a playmate or friendly companion who is genuinely interested in and
welcoming of the whole child, however they present.
Having fun is part of childhood and helps to build the relational field. If a child is
anxious and their breathing is shallow, I may suggest that we blow bubbles or play tin
whistles to see how much noise we can make. I may offer pieces of fabric doused with
aromatherapy oils, to support choosing between two scents, or tasting two different
fruits. Imay ask adolescents to bring their favourite music CD, or use fashion magazines
to create a collage of their ideal personal wardrobe. Guided imagery and meditation
techniques serve as strategies to calm and settle themselves in times of stress. Such work
also supports self-definition, and Oaklander (2006) gives numerous examples of helping
clients to use T statements, as they clarify who they are and who they are not.
Opportunities for play and ‘experiencing mastery’ (p. 28) are also important for cli-
ents who have had insufficient support and grown up too quickly. Even adolescents can
become absorbed in tidying the doll’s house, building lego scenes or writing a poem.
Through such activities they gain a sense of satisfaction in their achievement and con-
solidate their evolving capacity for self-support.

Expanding the Client’s Sense of Self

Once the sense of self is sufficiently robust, the experience of imaginative play enables the
therapist to support the client's imaginal world. Using whichever creative materials they are
drawn to, the client is encouraged to create a scene, and these scenes are often representa-
tions of their situation. Listening intently, the therapist invites the client to describe what
they have created, and to ‘be’ one or more of the characters, e.g. ‘I am the fat controller and
I decide where the naughty engines go. The therapist encourages the client to say more, and
asks questions, e.g. “Which engine is the naughtiest?’; “What do they do that is naughty?’
These projections offer the therapist a sense of the client’s world and the client experiences
being heard, accepted and responded to in their fantasy world. They also practise ‘experi-
menting’ (Parlett, 2000), where they begin to risk novel ways of being, acting and thinking.

Completing the Gestalt

The fantasy is a kind of a bridge into aspects of the self that they don’t even know are
parts of the self. The child begins to relate to those parts and gets to the point where
 Gestalt 73

they can own them. It’s like they're looking into a window of the self. (Oaklander
, in
Mortola, 2011: 346)

Oaklander does this by inviting the client to dialogue with the characters in their
picture or sand-play, e.g. ‘How could you help the fat controller?’; ‘What would you
like to tell him?’ She emphasises, however, that such work is founded on the thera-
pist’s relationship with and support for the.child, which enables them to engage in
the fantasy, relate to different aspects of self and own them. Such work strength-
ens ‘self-recognising’ (Parlett, 2000), or knowing one’s own truth, and young clients
may use the relationship with the therapist to develop and embody new compe-
tences, such as exerting power and control over others in the service of completing
Gestalten.
This stage also supports ‘interrelating’ (Parlett, 2000), the ability to relate to others
according to the needs of the situation. The process of gestalt completion may happen
within one session or take many sessions. The therapist needs to stay alert to the client’s
resistance surfacing at any stage, as expressed through a change in energy, or suddenly
diverting attention elsewhere. Such resistance is honoured and respected, so clients
learn to trust their natural cycle of contact and withdrawal. The therapist has faith that
that they will return to complete the gestalt when they are ready.

Brief Therapy

Houston (2003) provides a powerful rationale for the relevance and value of brief
gestalt therapy with adults. She offers the reader a useful framework for supporting the
client through their contact cycle towards completion of their need, and case studies
which illuminate how individual and group gestalt practice may enhance clients’ abilities
to impact and respond to their environment. Here I focus on three aforementioned
aspects of gestalt practice that support the relevance and value of gestalt for brief work
with children and young people.
First, gestalt emphasises process, or what is happening in the here-and-now
between therapist and client, whereby the client’s dominant need organises their per-
ceptual field. The therapist stays open to the totality of the experience of the young
person’s impact on them and uses this awareness to inform their way of being with
the client in the present moment. Second, the therapist is willing to enter their cli-
ent’s world as an attuned playmate or companion and meet them exactly where they
are. This experience of support helps to interrupt any shame processes, and affects
the client's self-experiencing at the contact boundary, potentially opening them up to
new possibilities. Third, the therapist is committed to support the client's potential
for creative experimentation so they may try out novel experiences (e.g. being the
centre of loving attention, expressing anger) as a means to complete their dominant
 74 The Handbook of Counselling Children & Young People

need or unfinished situation. Such work may take place within one session, or over
a number of sessions, depending on how successfully the ground of the relationship
is established.
Oaklander’s reports of her work with young clients demonstrate that brief work can
be effective for many children and young people, and in some cases may be as much
as they can assimilate at a given stage in their own developmental process. In the final
section I offer a brief account of contemporary research evidence for a gestalt approach
to working with children and young people.

The Research Evidence

Greenberg (2008) argues that process—outcome research studies have proved a valuable
way of generating evidence-based data on gestalt therapy with adults over many years.
Recently, gestalt practitioners working in the NHS found a practice-based research
network (PBRN) approach to collecting methodical, rigorous, clinically-based, mostly
quantitative data to be more workable in a context where minimum funding and vol-
untary effort is required. Their three-year study found gestalt psychotherapists to be as
effective as therapists trained in other modalities working in the NHS and in primary
care (Stevens et al., 2011). Although an equivalent study of gestalt therapy with young
people in the NHS is feasible, one is yet to be conducted.
Barber and Brownell (2008: 37) argue that ‘Gestalt therapists are practitioners who
work with direct perception to discover how a person is sensing, thinking, feeling
and imaginatively projecting information to constellate the world ... they are well on
the way to conducting qualitative inquiry. Trustworthiness is a key criterion when
assessing the reliability and validity of qualitative research (Krefting, 1991), and
Oaklander’s collected works are a prime example of such trustworthiness in action.
Her subsequent papers in Windows to Our Children (1988) and her latest book,
Hidden Treasures (2006), added to the practice-based evidence in the original volume,
and more recently set out the theoretical framework she created and developed over
60 years of practitioner-research.

Case Study Eze

Eze was 15 years old when she was referred for counselling as an alternative to exclusion from school.
Her tutor reported that Eze had arrived aged 14 with a glowing report of her academic and social
skills. However, neither had been evident since then and her attitude to authority, behaviour and
 Gestalt 75

—academic work had caused concern, despite teachers’ best efforts to engage her and hold her
‘
to
account. Her parents had apparently been uncooperative.
Initially Eze seemed hesitant, peeking a glance at me before plonking herself down on the chair
closest to the door. | sensed her resistance,‘Iguess you don't want to be here with me. | understand
-.. you didn’t choose to come. So we both need some time to check each other out’ She looked
askance at me, so | continued, explaining that | would meet her parents separately and explain our
contract together, including issues of confidentiality. When asked if she had any questions she sat
up and informed me that speaking to her parents would be a ‘waste of time’ | thanked her for her
honesty and asked ‘how are you feeling now you've told me that?” ‘Fine’ came the prompt reply. ‘Are
you willing to try something with me?’I inquired.’You can stop wheneveyou r want’ She looked non-
plussed but nodded. ‘Okay, let's take in some short, shallow breaths, like this. How was that?” ‘Easy.
‘Good, shall we try another way now?’ Eze nodded, so we took some longer, deeper inhalations and
exhalations. | noticed her face soften and her upper body relax as we did this, and we ended the ses-
sion with an agreement to ‘do more stuff like that’ the next week.
On meeting Eze’s parents, they insisted | get her ‘back on track. When | inquired whether any-
thing had happened that would account for the changes in her behaviour, they were quiet and
looked away. Her mother abruptly stood up and proclaimed, ‘it’s just puberty, it’s normal!’ before
walking out.
Eze and | continued to work together on sensory activities to deepen awareness of herself and
her preferences. One day she expressed some muted anger towards her parents and | invited her to
choose some objects to represent her parents and place them in the sand tray. She became totally
absorbed creating a scene with four figures, a lion cub lying in the sand with a lion on each side,
and another cub hidden from view behind a mud wall. She poured sand over the lying cub until
it was completely covered. | suggested she ‘be’ one of the figures in the scene and speak ‘as if’ she
were them. She looked embarrassed, so | encouraged her to focus on the breathing and grounding
techniques we had practised. Tuning into her growing capacity for self-support, she was able to
speak as the buried cub:'l want to live. Help me’ As the cub behind the wall she said, ‘l am so lonely.
| wish | had died, not you’ | was touched by the agony in her voice and took a moment before ask-
ing her what this scene meant for her. Tearfully, she told me her twin sister had died of acongenital
disease 18 months earlier. She had neither been allowed to visit her bedside towards the end, nor to
attend the funeral. Since then, it had been taboo to speak of her sister at home, as ‘it would kill her
mother’ Within six months of their bereavement her parents had sold the family home and moved

me J
to a new suburb.

Summary

© Gestalt works with the totality of the child’s relational field, and recognises the dynamic interplay of
field variables. These are experienced at the contact boundary between adult and child. Here, both
co-evolve in response to one another and the demands ofthe situation
76 The Handbook of Counselling Children & Young People

e It is assumed that everyone is doing the best they can with the resources they have in the
moment. This involves making creative adjustments to the situation in order to achieve a satis-
factory ending, or complete gestalt
e Shame and belonging are key field variables affecting experience at the contact boundary.
Two ways of being at the contact boundary are of particular importance for child develop-
ment: the way power is exercised and the way boundaries are organised to meet the child's
emergent needs
e The therapist is a fully embodied, energetically available presence and meets the child where
they are, offering an ‘I-Thou’ experience at the contact boundary. It is recognised that no
therapeutic work will occur until the relationship is established
e Gestalt therapy may be directive or non-directive depending on the demands of the situation
and the present moment. The therapist partners with the child and co-creates what happens
with as much support as possible and as little support as possible, to activate the client’s
organismic self-regulatory process
e Gestalt is a creative therapy and uses multi-sensory media to support the client’s experienc-
ing of self at the contact boundary, and hence self-definition. From this ground the client
can explore other aspects of self that have been neglected, become fixed or disowned in
some way
e Clients are helped to understand and own their feelings, offered opportunities to unblock
emotions that interfere with their capacity to function healthily, and to learn how to
express difficult feelings safely

Reflective Questions

1 There is a field between you the reader and the text. How are
you experiencing this field? What did you bring to the field by
way ofyour previous experience of gestalt? How did this affect
your reading? How, if at all, has your view of gestalt changed as
a result of reading the chapter?

This question provides an opportunity to explore what is co-created between the author
and reader. The aim is to support you in identifying your own cherished values and
 Gestalt 77

beliefs, and also to notice how you respond to the similarities and differences between
your own theory of practice and gestalt.

2 How do you currently engage with the relational field in your

own work with children and young people? How do you manage
the relational ethics within the field?

Working with adults in support of the child or young person can feel challenging,
and therefore it is important to establish the relational ethics involved at the outset.
The young person’s needs and voice are paramount, and unless contravening my legal
responsibilities, I would not disclose any information shared with me unless the young
person had given their express permission to do so. This is also true when working
with both parties, as with Eze in the case vignette. When working separately with a
parent or teacher, my key focus is on supporting their process, and helping them to
develop the attributes and skills needed to support the young person more sensitively
and effectively.

3 How do the concepts of embedding and disembedding work for

you when thinking about the child’s and adolescent’s relationship
with significant others? How might the way you exercise your
power and hold boundaries change over time as a child moves
through the school years?

Young child: power is exercised to support the child’s engagement in co-created expe-
riences to meet their dominant need at the time. In this way pressing or unmet needs
(e.g. for attention and care, self-definition, control, mastery) can be met. Within this
process the therapist holds boundaries conducive to novel experiencing whilst keeping
the child safe at all times.
Adolescent: power is exercised to support the young person's capacity for making
responsible choices, and then behaving appropriately and in accordance with their
choices. Boundaries are negotiated with the young person to support their growing
ability to hold appropriate boundaries themselves. If a young person fails to behave
appropriately, then the boundaries are collaboratively redrawn between the pair to sup-
port their joint learning from the situation, and without activating debilitating shame.
78 The Handbook of Counselling Children & Young People

i ?
*
i} Learning Activities
i

ead you reflect on the relational field in your family oforigin, or your current family, what is
the ground of the relationship? Consider individual and cultural factors, including roles,
values, norms related to social, emotional behaviour, etc. How do these affect the qual-
\ ity of your relating with significant others at the contact boundary?
yj 2. What memories do you have of adults playing alongside you to give you experiences
I of mastery, power and control? How were you supported by adults to find your voice
i (thoughts and feelings) as a child or adolescent?
i 3. Given the above, how might you respond to a young person’s desire to handcuff you or
i confine you to a chair under their orders? What further work might you need to do to be
i able to enter a child’s play world and meet them where they are as a character in their
i fiction or drama?
; 4. Think of ayoung person or client you know well. What is the balance of shame and sup-
' port in their life? Are you aware of any unfinished business that might affect their way of
1 being with you at the contact boundary?
y 5. How well equipped do you feel to work with parents to support their capacity to sup-
1 port your client? How would you manage the key issues of power and boundaries in
1 this situation?
Som ¢

Further Reading

DeMille, R. (1997) Put Your Mother on the Ceiling: Children’s Imagination Games. Cambridge, MA:
The Gestalt Press.
Kanner, C. and Lee, R.G. (2005) ‘The relational ethic in the treatment of adolescents’, Gestalt Review,
9 (1): 72-90.
Lampert, R. (2003) A Child's Eye View: Gestalt Therapy with Children, Adolescents and Their Families.
Cambridge, MA: The Gestalt Press.
Oaklander, V. (1979) ‘A gestalt therapy approach with children through the use of art and
creative expression, in E.H. Marcus (ed.), Gestalt Therapy and Beyond. Cupertino, CA: Meta
Publications.
Oaklander, V. (1992) ‘Gestalt work with children: Working with anger and introjects, in E.C. Nevis
(ed.), Gestalt Therapy: Perspectives and Applications. New York: Gardner Press.
Oaklander, V. (1999) Group play therapy from a gestalt therapy perspective’ in D.S. Sweeney (ed.),
Group Play Therapy: Theory and Practice. New York: Charles C. Thomas.
 Gestalt 79

Online Resources

BACP website: www.bacp.co.uk/ especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com.
 Becoming an Integrative
Practitioner
Niki Cooper and Kelli Swain-Cowper

This chapter includes:

e Common features of integrative practice

e The challenges and benefits of becoming an integrative practitioner
e An integrative practice-based model which uses a developmental perspective to integrate
aspects of attachment, psychodynamic, person-centred, play therapy and systemic thinking
e Acase history to illustrate core principles of theoretical synthesis

Child practitioners, especially those working in settings with a socially and cul-
turally diverse client group, often find themselves making use of a variety of
therapeutic models and techniques to meet the needs of the children they work
with (Warr, 2009).
It is hoped that what will emerge is an understanding of how the different schools
of counselling are essentially, as Castonguay (2006) said, ‘trying to make sense of the
same beast. As such, they do not always contradict each other but can offer helpfully
complementary perspectives which give a fuller dimension to our understanding of the
children and young people with whom we work.
 Becoming an Integrative Practitioner 81

Introduction

The world of counselling and psychotherapy has a tradition of warring schools of

thought or ‘schoolism, which took root in the earliest days of its development. At pre-
sent, the accrediting bodies are still structured along model-specific lines. As Mick
Cooper (2008) bemoaned, much energy has been wasted in writing and research
which simply seeks to prove which model is best and most effective. In fact, the most
consistent finding in therapeutic research suggests that the models are equal in terms
of effectiveness and that there are other variables which are much more predictive of
positive change (Cooper, 2008). We are a long way from having all the answers about
best practice with children. Our commitment must be to keep the dialogue alive and
practice-led. ‘Schoolism is perhaps an understandable strategy to manage the uncom-
fortable muddle that is the human psyche, yet it limits the creative possibilities in
evolving our understanding and practice.
There are many ways to feel better and more functional in the world. As practitioners
we are not doing anything extraordinary. We are simply, as Lomas (1981) suggested,
manifesting ‘creative human qualities in a facilitating setting: Everyone can be helpful
to some people some of the time. Our mission as counsellors, especially for children
and young people, is to strive, with humility, to develop and broaden these ‘creative
human qualities’ so that we can more accurately attune to the needs of a diverse range
of others. That way we can be helpful to more people more of the time.

History and Background

Although the name ‘integrative’ is a relatively new title for a way of working, in fact
practitioners have been continually integrating new concepts to existing frameworks
throughout the history of psychotherapeutic work. It is, however, the legacy of ‘school-
ism’ that many innovative clinicians and theorists have been eager to be associated with
or set directly against existing historical positions. It is a recent development that clini-
cians have openly acknowledged finding a variety of theories from different historical
lines relevant to practice and have coined the term ‘integrative’ practice.
What do we really mean by ‘integrative’ practice and how does this differ from what
some might describe as ‘eclectic’ or ‘pluralistic’ practice? Eclecticism is where different
tools and techniques from different schools are used without any particular regard to
their philosophical underpinnings (Hollanders, 1999). A pluralistic model suggests that
each client needs different interventions at different stages of their therapeutic jour-
ney (Cooper and McLeod, 2007). Integration is where diverse theoretical concepts and
82 The Handbook of Counselling Children & Young People

techniques have been synthesised together to form a new coherent theoretical position
(Hollanders, 1999). Arguably, ‘integrative’ practice itself could be viewed as the forma-
tion of yet another ‘school’ of thought. The difference may be that ‘integrative’ practice
directly pays homage to each of the historical evolutions from which it borrows.
Some research suggests that although just 42 per cent of experienced counsellors
declare themselves to be eclectic or integrative, as many as 98 per cent make use of
techniques from different theoretical orientations (Cook et al., 2010; Hollanders
and McLeod, 1999; Schottenbauer et al., 2007). A recent national scoping report of
counselling in primary schools (Thompson, 2013) estimates that 61 per cent of the
child practitioners would call themselves integrative and that play-oriented, art, and
psycho-educational techniques are used by at least half of all responding individuals
and organisational providers. This research implies that the reality of the work with
children requires elements of theoretical and technical integration. Even if practition-
ers openly acknowledge the integrative nature of their practice (Cook et al., 2010), it
is hard to know what exactly these therapists ‘really do in practice. Identifying core
principles which define how theories can be woven together to connect and co-create a
therapeutic relationship is the topic of this chapter.
The process of synthesising different frameworks into a coherent position presents a
number of challenges to both the individual and training programmes. It is dependent upon
defining an underlying philosophy which will consequently influence which theories
one uses to conceptualise the very nature of what it means to be human (Gilmore,
1980). There are an infinite number of possible combinations of theory and the specific
manner in which they are interwoven will, necessarily, be affected by the personality of
the training, the tutors, the supervisors and that of the practitioner. In support, McLeod
(2004) argues that good counselling - and, by inference, training - must be authenti-
cally grounded in our own experience and values rather than a wholesale adoption of
a set of skills and techniques. Being familiar with the assumptions that we bring to the
work can enable us to ensure that our practice is not limited or confined by our own
social or cultural constraints, yet assist us in finding an authentic presence in the work.
Together, these are perhaps some of the influences which come together to define what
Stern et al. (1998) refer to as the ‘therapist’s personal signature.
There are a number of examples of therapists who have created integrative models
for work with children. Dowling and Osborne (2003) combine the systemic family
theory and traditional psychoanalytic thinking to a child in the context of home
and school.
Grehan and Freeman (2009), Holm-Hadulla et al. (2011) and Geldard and Geldard’s
(2010) models generally support the idea of a:

® person-centred approach for the therapeutic relationship

¢ psychodynamic thinking for processing and surviving the complexities of the relationship
 Becoming an Integrative Practitioner 83

e systemic thinking for looking at the social and cultural context of the child to locate
obstacles to change and conflicts in cultural norms
e cognitive-behavioural approaches to change behaviour and/or thinking.

These approaches see the components working together in different ways. The cre-
ative challenge for an integrative practitioner is to find and identify the underlying
philosophy that will make for a ‘coherent’ theoretical position that is helpful in practice
(Gilmore, 1980).
Hollanders (1999) identifies what may be another challenge to becoming an integra-
tive practitioner, suggesting that integration is an ever-evolving process rather than a
fixed position. This makes for a journey of perpetual uncertainty and, conversely, pos-
sibility. Lowndes and Hanley (2010) highlight the difficulties for trainees on integrative
training programmes in tolerating the anxiety raised by theoretical contradictions and
ambiguity. However, they agree with Ladany et al. (2008) who propose that ‘tolerat-
ing ambiguity is an important aspect of any counselling practice’ and that managing
ambiguity and not-knowing leads to a more collaborative client-led practice. Perhaps
the challenge of becoming an integrative practitioner is ultimately a benefit in working
with the ‘untameable nature of clinical reality’ (Castonguay, 2006). It is the integra-
tive practitioner who has developed a capacity to manage the inevitable ambiguities,
uncertainty and not-knowing who can remain open to the creative potential and the
possibility of meeting the child in a collaboratively defined intersubjective moment.

Theoretical Underpinning: Theory into Practice

Identifying Practice-Led Core Principles

The integrative model we are presenting views each therapeutic journey as a unique
series of co-created moments. However, we have identified core factors which facili-
tate growth and resilience in children and young people and bring about therapeutic
change (Lee et al., 2009). These consist of:

e building a therapeutic relationship

e the ongoing development of self- awareness in the counsellor and the child or young person
® engaging with children, young people and adults through the medium of play or playful-
ness in its broad sense

Use of these core factors in our integrative practice has yielded positive outcomes, with
82 per cent of teachers and 74 per cent of parents noting positive changes for the child
as a result of the therapeutic intervention (Lee et al., 2009).
84 The Handbook of Counselling Children & Young People

The identification of these core factors which affect change is not, however, a ‘coher-
ent theoretical position, as earlier defined. Yet it becomes clear that any relevant model
for working with children and young people must address these core principles.

A Practice-Led Integrative Model

This chapter presents our model for working with children. This model has been influ-
enced by the work of diverse practitioners across the field working with children and
young people for the last 20 years. Gilmore (1980) states that any integrative model for
practice must begin with a general theory of human behaviour built over a foundation
of philosophical assumptions. The model of integration presented here begins with the
‘general theory that children and young people are oriented toward growth, develop-
ment and forming relationships, and that the nature of these relationships will affect
the development of the self. We believe that, from birth, humans are driven to form
secure bonds with others and that the capacity to make and build helpful relationships
is the cornerstone for sound mental health (Holmes, 2010). Play, in its widest defini-
tion, is an integral language to facilitating this process of development. And finally, it
is through these relationships and experiences that children develop and evolve a sense
of themselves which influences their way of functioning in society.

Transcultural Challenges

An evaluation of this general theory will reveal that the underlying ‘philosophical
assumptions (Gilmore, 1980) place an emphasis on a relational-based self-understand-
ing and identity, the importance of play, the social context of mental health, the primacy
of early carer relationships and an implicit valuing of a child’s experiences. Many assump-
tions which underpin counselling trainings, both in the content and structure, have a
Euro-American cultural standpoint (Watson, 2011). For example, some cultures may
place a greater emphasis on the ‘we’ rather than the ‘T,; more importance on the commu-
nity or intergenerational aspects of carer relationships over the mother (Music, 2011),
or privilege religious or spiritual philosophy over social context in the understanding
of mental health. Music (2011) poignantly exemplifies the subtleties and power of such
differences when he cites a study where mothers of two different cultures are shown
videos of each other's caretaking styles, resulting in each group’s cringing bewilderment
at the other. Given the vastness of cultural differences, we cannot hope to achieve a
fully global perspective, but perhaps, as McLeod (2004) argues, being explicit about our
beliefs and values, aware of a tendency toward ethnocentricity and acknowledging the
 Becoming an Integrative Practitioner 85

cultural limitations of our assumptions, we can remain more flexible and open to a dia-
logue that will aspire to greater inclusivity, open acknowledgement of difference and
increased accessibility.

Relationship, Self-Awareness and Play: Using a Developmental

Perspective to Weave Together an Integrative Approach

Our understanding of an integrative model is a weave of attachment and child devel-

opment theory; person-centred presence, regard and empathy for the other with the
offering of relational depth; a psychodynamic understanding of the conscious and
unconscious forces within therapeutic transference relationship; and an understanding
of the early childhood ‘dance’ of intersubjectivity which influences the child’s dance
of life and the dance within the therapeutic space. The model we have presented is
but one way of integrating different therapeutic understandings, theories, experiences,
research and philosophies into a working model of practice, and we include it here as
an illustration of integration. Many child psychotherapists argue that the traditional
case study remains a useful form of research which most clearly demonstrates effective
ways to practise (Reid, 2003; Rustin, 2003) and most accurately represents the qualita-
tive, investigative and interpretive nature of therapeutic work. We continue with an
illustration of how our model is applied in practice.

;
Case Study Abdi
Background and Referral
Abdi is 10 years old. He is Somali and arrived in Britain when he was five years old. He lives with his
mother and two older sisters. Abdi has attended a primary school in South London where there is a
well-established Somali community. It was four years before the family were granted leave to stay in
Britain. All of the teachers in the school are white British and female. Abdi has been referred to the
school counsellor by the inclusion manager in the school because he is often in trouble for fighting
on the playground, does not appear to have formed any close friendships and the rest of the class
seem wary of him, and his attainment is below expectation for his age.
Goals and preferred outcomes are influenced by one’s philosophical assumptions and judge-
ments. Each adult involved with Abdi will have differing perspectives on what would bea positive
change for him and different ideas about how this change might be achieved. Counselling may
(Continued)
 86 The Handbook of Counselling Children & Young People

(Continued)

not be the preferred method for achieving change for each of these individuals. By acknowl-
edging personal preferences it is more possible to see where assumptions may be limiting the
possibilities of connecting helpfully with Abdi and the systems around him. Behaviour support
or extra tuition could possibly also address the priorities and beliefs of his teacher or his mother.
As integrative practitioners, we would want to support this and hold in mind his relational needs
as well.

Assessment

Mother
The counsellor, John, met with Abdi’s mum for an assessment session and learnt the family’s story.
Mother described the family in Somalia, her husband and two daughters, as being secure, settled
and thriving. She recounted being excited about the idea of having their third child when she discov-
ered she was pregnant. She described the shock and fear when a sudden outbreak of war ravaged a
nearby village. Her husband had quickly organised for her and the girls to flee to a Kenyan refugee
camp. He had planned to send for them when the trouble had passed, but she had never heard from
him again. She confided that she had suspected he had been killed, but that as she was not sure she
didn't ever talk about it to the children.The uncertainty around her husband's whereabouts and the
rudimentary facilities in the refugee camp had made her depressed and unsettled in the time fol-
lowing Abdi’s birth until their move to London. Abdi had always been very difficult and demanding
and she felt he had missed out on having a man about to discipline him. Things were still difficult
for the family as they had only recently been given leave to stay in the UK, but she was feeling more
settled and optimistic now. She explained that his two sisters were doing well at school and had
formed good relationships both in and outside of school. She had friends and family in the area and
was volunteering for a local Somali family project. She wanted Abdi to settle down at school so that
he could learn and behave more respectfully at home. She expressed concern that he might get into
more serious trouble when he moved to secondary school.

Abdi
In the assessment session Abdi moved constantly and flitted excitedly from one play activity to the
next, leaving a trail of toys and mess behind him. He spoke English well, but described his activities
in short, fragmented sentences. He did not make much eye contact and did not appear to want
to talk about his life outside of the room. When the counsellor gently spoke of the concerns of his
teacher and mother, Abdi looked fleetingly out of the window and continued to move around the
room. Abdi seemingly ignored the counsellor at first, then later said that he was good at football,
but that he was always treated unfairly by everyone. He said he liked coming to the lunchtime self-
referral sessions because he liked playing and drawing. He was delighted to be offered more time
Ce the playroom.
=z)
 Becoming an Integrative Practitioner 87

Formulation

An understanding of the importance of the early mother-child relationship in the devel-

opment of the self influenced the counsellor’s thinking. The work of Bowlby (2005),
Winnicott (1965), Bion (1965) and Stern (1985) places importance on the capacity of
the mother to emotionally attune to the infant’s communications in order to help the
baby manage and make sense of the chaotic array of stimulation from within and with-
out that he is as yet unable to do himself. Stern (2004) viewed the mother’s repertoire
as offering vitality, experiences of being with an other and a co-regulating other. The
dance between a mother and baby would be responsive to the baby’s innate senses of
self, which Stern referred to as the emergent self, the core self and the core self with an
other. These selves are described as a newborn baby’s sense of its own integrity as sens-
ing, experiencing, continually existing beings with some awareness of and readiness
to experience and engage with an other. He saw these domains of self as co-existing
and forming the basis for relationship, or what he referred to as core-relatedness. It
was also the foundation upon which other domains of self, e.g. the intersubjective, ver-
bal and narrative self, would later be layered on top. Stern saw these selves as existing
together like strings on a violin and viewed our interactions and activities as activating
or attending to different selves at different times. He viewed it as possible to have them
all vibrating in harmony, or simply one or two at a time.
The counsellor thought that the dislocation, trauma and hardship of securing basic
needs would have likely affected Abdi’s mother’s sense of self, which in turn would
impact on her capacity to provide such emotional attunement, playful and co-regulating
experiences with her baby - perhaps, at times, leaving Abdi with a sense of overwhelm-
ing anxiety and a feeling of ‘falling to pieces’ (Horne, 1999). In light of Bowlby’s (2005)
attachment theory and Erikson’s (1965) ideas on child development, a fundamental
sense of trust and security would have been at stake in these early experiences. Abdi's
domains of self and first experiences of being with and co-regulated by an other, the very
foundations for intersubjective experiences, may have thus been affected (Stern, 1985).
Taking a systemic perspective, the counsellor was also aware of how isolated Abdi was
becoming in the school by being ‘sent out’ of both his class and his football games. He
had become the ‘excluded’ one. Culturally, his family had been uncertain of their ‘right
to belong’ in Britain for their first four years of living there. While his mother and sisters
were achieving and thriving, Abdi held a place within the family system of being undisci-
plined and reckless with his educational and social opportunities, which were deemed by
his mother as very important. He compared Abdi’s mother’s belief that what her son was
missing was a ‘man to discipline hin’ with what the school was offering - an empathic
counselling relationship. This made him aware of the potential for culturally-conflicting
messages between the predominantly white British female school staff and Abdi’s Somali,
88 The Handbook of Counselling Children & Young People

mergent self
The sense of an €
Birth 9 mo. 18 mo. 3 yr.

Figure 6.1. The interpersonal world of the infant (Stern, 1985: xxv).

Muslim, first-generation immigrant home culture. His presentation as the ‘one who does
not belong’ made sense in the context of his worlds.
Abdi did have resiliencies to build on. He had made use of the self-referral lunch-
time service and enjoyed the play and artwork that he had done in the room. He had
used this service repeatedly, demonstrating that his internal expectations of relation-
ships did allow for the identification of some helpful relationships and a willingness
to seek them out. Although he had found the assessment difficult, he had been able to
stay in the room for the whole session, suggesting that he might be able to find a safe
place in the room for one-to-one work. His engagement in artwork showed his capacity
to create which, according to Winnicott’s (1991) idea of transitional space, necessarily
indicated some aspects of ‘good enough early parenting. The family was now settled and
his mother cared deeply about Abdi's success at school. He was part of a supportive com-
munity and motivated to play football. The counsellor decided that he would continue
to work with Abdi’s mum and teacher to ensure that their perspectives were honoured
and that there was consistency in the adults’ approach to him. He also offered Abdi one-
to-one weekly counselling and hoped that having his story heard would create a secure
enough base from which Abdi could begin to experience the world in a less uncertain
way. This would, in turn, make him less anxious in the learning setting and more able to
concentrate and maintain helpful relationships with his peers and other adults.
 Becoming an Integrative Practitioner 89

Beginning the Relationship

The play room was equipped with a range of play and art materials, including a sand
tray, an array of small world figures, paints, modelling material, coloured pens and
pencils, and puppets. John, the counsellor, spent the first session with Abdi drawing
up a contract for their work together which named the basic boundaries of safety for
them both, the times and days of their sessions, and an explanation of the limited con-
fidentiality that John could offer. Abdi chose to draw pictures to represent the contract
but finished as quickly as he could, saying that he wanted to come for counselling so
he could be captain of the football team and so he could miss numeracy. John told him
that he was a person in the school who listened carefully to the children’s feelings and
the things they think about. He explained that play and art are sometimes a good way
of working things out and making sense of things together and that when he came here
he could choose what he might like to do. They agreed to use the time together to think
about how he could get better at football and what he would need to do to become
captain.
John, inspired by person-centred play therapy, offered warmth, a positive regard and
empathy to Abdi (Axline, 1990 [1971]). He viewed Abdi’s process of development as
driven by an actualising tendency and felt that if he offered the right conditions to
Abdi, he could fulfil his potential. He allowed the child to lead the play and choose
what he wanted to do in the room. However, forming a helpful relationship with Abdi
was challenging.
John sat alongside Abdi while he moved from one activity to another. Abdi would
use fragmented sentences to describe some goodies or baddies, but this seemed more
inwardly directed. Using his knowledge that play involving ‘goodies and baddies’ was a
common strategy for middle childhood management of anxiety (Canham, 2006), Abdi’s
play seemed developmentally appropriate. John observed Abdi carefully and noticed
that they rarely made eye contact. John felt invisible, bored, and found it difficult to stay
focused on Abdi’s play. Abdi enacted one battle after another. At the end of each story
everyone died and no-one came to the rescue. John reflected aloud on the stories, offer-
ing some emotional and narrative reflection on the battles. He got no response and the
battles continued on in the same manner. This persisted for a number of weeks.

Supervision

In supervision John and the supervisor considered Abdi’s apparent rejection of John's
verbal reflections and John’s sense of being bored, invisible and useless. They discussed
the possibility that John’s sense of not mattering and being invisible was a projection
90 The Handbook of Counselling Children & Young People

from Abdi describing his own internal experience. John’s lack of attentiveness may have
been a counter-transference response to Abdi’s transference to John as a preoccupied
and disconnected parent.
John and his supervisor were making use of an understanding of transference and
counter-transference, developed from psychoanalytic and attachment-oriented ther-
apy, which understands that a client’s internal relationship models will be consciously
and unconsciously communicated in the therapeutic relationship. They considered
John’s withdrawal and disconnection as a counter-transference response which, by
thinking about it together, meant John could respond to the boredom and inattentive-
ness in a helpful way rather than acting it out. Awareness of the transference led John
to realise that despite the warmth and good intention that he thought he was offering,
Abdi’ internalised expectations of relationships, expressed in his verbal and non-verbal
communications, were pressuring John to repeat these earlier caregiver experiences.
This realisation allowed John to stay alive and empathic to Abdi’s vulnerability being
expressed in the endless battles.
They also considered Abdi’s metaphorical play of endless repeated battles with no
helpful or organising authorities. The supervisor assisted John in linking this to Abdi’s
history, and both posited that the circumstances around his early childhood made it
probable that his mother’s availability to offer a ‘co-regulating other’ may have been at
least partially jeopardised, leaving Abdi’s core sense of self with a co-regulating other
disrupted, fragmented. This could make him easily overstimulated in moments of
relating. They also considered the absence of his father and Abdi’s mother’s feeling
that order, albeit in the form of discipline, had left Abdi without a sense of structure
(Horne, 1999). In reference to the transference relationship in the here and now, they
considered the likelihood that Abdi was currently experiencing a doubtfulness that
John could offer any help in making sense of things.
They concluded that Abdi’s lack of response to verbal interventions appeared to
show that Abdi was not ready for an intersubjective moment that was expressed ver-
bally and narratively. In referring back to Stern’s (1985) layered domains of self, they
viewed John’s rejected attempts to narrate the play in order to attune to Abdi as ‘pluck-
ing the wrong string. They felt that Abdi’s non-verbal selves, particularly the core self
with another, would need to be attuned to before any experiences of intersubjective
meeting could happen.

Deepening the Relationship

In the following sessions John felt a deepened sense of empathy for Abdi and observed
him more closely and spoke less. He mirrored Abdi’s body language and breathing and
when Abdi vigorously threw a tiger down into the sand, John mirrored him. Abdi looked
 Becoming an Integrative Practitioner 91

at him wide-eyed and grinned. He picked up another figure and did the same. John fol-
lowed him and this continued for the rest of the session. At times John ventured into a
cross-modal sound reflection, offering a playful hmph or grrr when it matched his move-
ments, gently bridging the domain from Abdi’s non-verbal selves to a verbal self. This
time Abdi was delighted and they experienced an intersubjective moment, a sense that
an inner experience had been shared. This represented a significant step forward in their
relationship. John had attuned to Abdi’s pre-verbal senses of self. Like a mother in the
early infant dance, he used his body, his expression, his deeply felt empathy to offer Abdi
a chance for his core selves to be in the presence of, resonating with and co-regulated by
an other. At the next session the battle of the goodies and baddies continued — only this
time an ambulance arrived to tend to the wounded. The work with Abdi was slow and
painstaking. John continued to deepen the relationship by focusing on Abdi’ pre-verbal
domains of self and by being consistent and holding the boundaries of the contract.
By the end of the first term Abdi had invited John to join in with his storytelling, and
was using a wide variety of media to tell his stories. He would spend more time on one
activity before moving onto the next. He enjoyed painting different characters and ask-
ing John to give voices to them. At first John checked everything he did with Abdi before
he did it (What kind of a noise does the evil T Rex make? How fast does he move?). Later
on, when John was confident that he was properly attuned to Abdi, he was able to make
bolder interpretations and connections. He did this either in the metaphor by giving
voice to the experience of one of the characters or by stepping out of the play to wonder
how a character might deal with a situation. John’s invitation into the storytelling began
to address the narrative self by co-creating a literal metaphorical narrative. Abdi’s use of
John to fill in the narrative corresponds to the role a parent takes in co-creating a coher-
ent narrative for a toddler. John was also aware of Abdi’s still fragile sense of pre-verbal
self and continued to be mindful of when this needed attention.

Ending

As the work was coming to an end, John and Abdi were firmly venturing into Abdi's
sense of verbal and narrative self. There were occasions when Abdi talked about home,
Kenya, or his classmates, and they wondered together about Abdi’s thoughts and feel-
ings. John remained aware that Abdi might still need additional support in building a
more coherent narrative about himself and his experiences at some point in his future.
He was aware that Abdi’s verbal and narrative self had been affected by sudden changes
in language and culture and that the absence of Abdi’s father had only been touched
upon when it had been present in the transference. John felt that Abdi might one day
need to make greater sense of the loss of his father and incorporate it into his narrative
understanding of himself. However, John felt confident that Abdi was taking with him
 92 The Handbook of Counselling Children & Young People

a different kind of ‘good enough’ experience of a helping relationship and would be

more likely to seek out this kind of help when he needed it.

Behavioural Change

John met with Abdi’s teacher and together they thought about Abdi’s difficulties in expe-
riencing others as helpful in regulating his experiences. She began to notice when he
was likely to become anxious and unregulated and could intervene earlier by respond-
ing to his pre-verbal needs immediately with a touch of his shoulder or an offering of
eye contact. Her physical attentiveness enabled him to engage with the mostly verbal
tasks on offer. She found that he was more focused in class and more able to engage
with help to raise his achievement levels. By the end of the year, she reported that Abdi
had managed three matches in the football team without being sent off and appeared
pleased with himself and able to survive the moments of tension and excitement.
Practice-led models require us to truly listen to the children and young people that
we work with and when we do, we believe, an integrative approach is inevitable. Abdi
benefitted from an integrative approach which made use of a developmental perspec-
tive which wove together person-centred, psychodynamic and systemic interventions.
Play, music, drama, art and movement are essential tools in work with children and
young people because they can offer a language to explore pre-verbal aspects of the self.
John’s use of this integrative framework gave him the tools and the thinking to find a
way to offer Abdi both non-verbal and verbal ways of making sense of himself and his
world and experiencing an empathic connection. A brief therapy approach would not
have been appropriate for Abdi because he needed time to build the foundations of his
pre-verbal self. Brief therapy requires the pre-existence of this solid foundation.

Summary

This chapter has argued that:

e Integrative models require a sound, coherent theoretical basis within the practitioner, but are
flexible and responsive to each co-created therapeutic relationship. An integrative interven-
tion is tailor-made and not duplicatable
¢ The integrative practitioner's capacity to connect with children is enhanced by attending,
attuning to and communicating with the verbal and non-verbal layers of self in relation to
communications from the child and by using self-awareness helpfully
¢ Maintaining coherence, authenticity and flexibility to co-create unique therapeutic relation-
ships requires the integrative practitioner to have a commitment to ongoing training and
self-development in order to stay open to an ever evolving approach to the work
 Becoming an Integrative Practitioner 93

e Continuing to articulate what we do and why means that good practice can be shared and
the dialogue can continue
¢ Qualitative studies of therapeutic work with children offer useful insights into best practice
across all modalities (Day et al., 2006; Carroll, 2002; Green and Christensen, 2006). The insights
gained from qualitative investigation of what actually happens in the counselling room may
then be shaped into questions for larger qualitative and quantitative studies to establish its
effectiveness

Reflective Questions

1 From a systemic perspective, what might a more extensive,

supporting intervention by the counsellor look like?

In his assessment, John may become aware and focus on the relationship that home
(mum and family) and school (school staff, ethos, and their responses to cultural
requirements/laws/standards) have with each other. Very often in such cases as Abdi,
there exist some undercurrents of blame between the two systems which make it dif-
ficult for the two systems to come together in their thinking about change (Dowling
and Osborne, 2003). Dowling and Osborne (2003) warn against ‘blaming’ and the
search to pin down ‘who must change’ and instead support the idea that a person
in a ‘meta’ position, outside of, yet connecting, the systems can provide an impetus
which invites a shift in perspective. The counsellor, in a ‘meta’ position between the
two systems, could be just this sort of impetus for a change in the interactions and,
ultimately, allow Abdi more opportunity to widen his experience beyond being the
‘excluded one’. Each small shift in the perspective or experience of any of the key people
in Abdi’s story may lessen the possibility of Abdi remaining in the position of the
‘excluded’ one, but this is only possible if each system can move away from a position
of blaming the other. Enabling this shift in perspective is something the integrative
practitioner may be able to effect.

2 What might a follow-up intervention look like for Abdi?

Transitions and changes, especially the transition from primary to secondary schools,
are anxiety provoking and difficult for many children and families to manage, even
for the most resilient and supported ones. This is even more so for children who have
had disruptive events in their lives or difficult early relationships, as in the case of
Abdi. Good practice has shown school staff building links, ensuring that information
94 The Handbook of Counselling Children & Young People

regarding a child’s educational, emotional and behavioural needs is passed on. Many
secondary schools provide an induction morning, allowing Year 6 students to visit their
new school. In Abdi’s case, identifying key named people (such as a Year 7 head of
year) or support services (such as a drop-in service or school counsellor) to both mum
and Abdi may assist them in identifying helpful people to go to when in need of sup-
port. Such communication, seemingly simple, but at times technically difficult to carry
through, goes a long way toward trying to hold the child in mind in the gap between
the primary and secondary school systems.

3 What race, culture and age did you picture John to be?

The race, ethnicity and age of John are not mentioned in the case study. If you
had an impression or image of him, it may be useful to examine what it was like.
We generally associate characteristics of benevolence, altruism, thoughtfulness
and hopefulness with counsellors, and it is useful to think about the race, ethnicity
and age that you may associate with these general characteristics. We believe that
this is an important aspect of developing self-awareness to recognise your own
assumptions and biases. Lanyado (2004) reminds us of the importance of our
presence as a therapist in the room, especially when working with children where
you will be face to face and sometimes physically interacting in play. While some
theories may suggest that your individuality should be kept out of the room, we
suggest that this would be impossible and that self-awareness should be developed
to ponder such things as: How might an other see me? What labels might they
give me? How might this child see me, my clothes, my haircut, my race, my accent,
my age, my class, my ability/disability, and what might their associations be with
‘someone like me’?

ee ge eh re nee mere eee eee ee ee aR ae A OO SN | MEL ay ay

»
Learning Activities

Activity 1: Practise Being with Another, Focusing on the Non-verbal ‘Domains of Self’

When we have a conversation with a friend, our focus is on connecting and communicating
with the other through our‘narrative’ and ‘verbal’ selves. At times, many new child counsel-
lors are less aware of and sensitive to both their own and others’ non-verbal ways of being
and communicating.
Sit with a willing other and try, without using words, to connect and attune to them.
eee
*
 Becoming an Integrative Practitioner 95

Oe ee re) em ecm ee es nn oon ley ss Smeg em

Experiment with your body positions:

e sit side by side

e move closer and then further apart
e sit facing each other
¢ move closer and then further apart
e one of you sit on a chair, the other on the floor
e adjust how you are sitting
¢ monitor your physical and emotional responses to the different positions and distances
e reflect together on the ‘dance’ between you and discuss what made you feel connected
and understood and what was uncomfortable
e did your perceptions differ?
e how aware were you of your partner's felt experience?

Activity 2: Supervision Activity for Abdi

Daniel Stern's child development model suggests that both verbal and pre-verbal aspects
of self need to be attended to in order for a child to thrive emotionally. This activity helps to
articulate how Abdi’s layers of self are being addressed.
* Choose one small world figure to represent Abdi’s verbal layers of self and another to
represent Abdi’s pre-verbal layers of self. Think about which object or figure you choose
for each and where they are placed in relation to each other.
e Choose more small world figures to represent Abdi’s mother, his father, his sisters, his
peers, his culture, his teacher and John.
e How might these figures relate to each other, what might they say or need from each
other? Would another constellation of figures be more helpful to Abdi’s well-being?
What would need to change?

Activity 3: Becoming an Integrative Practitioner

The integrative practitioner also needs to attend to both verbal and pre-verbal aspects of
themselves in order to fully attune with all aspects of their child clients. This activity helps
to articulate how the counsellor is addressing their own layers of self.

e Choose one small world figure to represent your verbal layers of self and another to
represent your pre-verbal layers of self.
e Then choose figures to represent your training, your supervisors, your course tutors, one
of your current clients and your other non-professional sources of support.
e What relationships exist between these figures? What might they have to say to each other?
To develop as an integrative practitioner are there any figures that need to change or move? Aa

® &
96 The Handbook of Counselling Children & Young People

Further Reading

Alvarez, A. (2012) The Thinking Heart: Three Levels of Psychoanalytic Therapy with Disturbed Children.
London: Routledge.
Recommended to begin to conceptualise different levels of intervening in the therapeutic work
with children, which we believe bridges very well with Stern’s different layers of self.

Geddes, H. (2005) Attachmentin the Classroom. London: Worth Publishing.

Recommended to build an understanding of how attachment patterns in children affect their
classroom behaviours and approaches to learning.

Kalff, D. (2003) Sandplay:APsychotherapeutic Approach to the Psyche. Cloverdale: Temenos Press.

An introduction into the world of sand-play and small world figures in psychotherapeutic play.

Kegerreis, S. (2010) Psychodynamic Counselling with Children and Young People: An Introduction.
London: Palgrave.
A good introduction to the dynamics of the counselling relationship and understanding transfer-
ence and counter-transference.

Landreth, G. (2002) Play Therapy: The Art of the Relationship. New York: Brunner-Routledge.
An overview of a person-centred approach to play therapy.

Lanyado, M. (2004) The Presence of the Therapist: Treating Childhood Trauma. Hove: Routledge.
A sensitively written book which acknowledges our ‘presence’ as therapists and as an individual
person and how who we are affects the work in the room. This book uses descriptions of powerful
case material to illustrate this.

Wilson, P. (2004) Young Minds in our Schools: A Guide for Teachers and Others Working in Schools.
London: YoungMinds.
A guide for school staff describing how children may bring their life experiences into the school
in their behaviour and interactions.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People
Counselling MindEd: http://counsellingminded.com.
 Play Therapy
Lisa Gordon Clark

This chapter includes:

SRC ARRAN ea SAREE IOI RSE TETOTTI STEEN OOSSSSSOPP EB LEVEL SEDIA TOES ESI2 BLIGE BELLI PGIESE EEE,

e Play therapy’s theoretical underpinnings and evidence base from a historical perspective
e Acontinuum of play therapy approaches from non-directive to directive
e Suggestions regarding setting up play therapy in a school setting
e Acase study to illustrate a fairly typical play therapy process

What Is Play Therapy?

Following several years as a primary school teacher, latterly supporting children with
special educational needs, I trained as a play therapist at Roehampton under Ann
Cattanach in the mid-1990s and since then have worked both in private practice and
as resident play therapist at a child and family centre in London. I am currently pro-
gramme convener of the Play Therapy MA at the University of Roehampton. In this
chapter I will describe the increasingly recognised, reputed and respected therapeutic
approach with children and young people: play therapy.
In 1996 The British Association of Play Therapists adopted the following definition
of play therapy:

Play Therapy is the dynamic process between child and play therapist in which the child
explores at his or her own pace and with his or her own agenda those issues, past and
98 The Handbook of Counselling Children & Young People

current, conscious and unconscious, that are affecting the child's life in the present. The
child’s inner resources are enabled by the therapeutic alliance to bring about growth
and change. Play Therapy is child-centred, in which play is the primary medium and
speech is the secondary medium.
Play Therapy encompasses many approaches but the foundation of all approaches is
child-centred. (www.bapt.info/aboutbapt.htm)

Whilst there is a spectrum of approaches in current play therapy practice within the
UK, all share the understanding that play is the natural, instinctive means through
which all children learn, communicate and explore their worlds and gain a sense of
identity. Play is universal and vital to every child’s social, emotional, cognitive, physical,
creative and language development. It is generally held that conventional talking therapies
are inappropriate for young children who struggle to find the words to describe com-
plex feelings. Rather than having to explain what is troubling them, as adult therapy
and more cognitive approaches usually expect, in play therapy children use play to
communicate at their own level and pace, without feeling pressurised or interrogated.
The symbolic distance of play enables children to express their feelings, thoughts and
beliefs surrounding difficult life experiences. These experiences are explored and made
sense of through the dynamic interaction between the child and the play therapist.
Play therapy utilises metaphors inherent in children’s play, art and narratives; there-
fore it feels less threatening for a young person than the expectation that they explain,
describe or depict factual reality. This symbolism has been termed ‘aesthetic distance’
and is critical for the safety of the abused child (Cattanach, 1997). Play therapy is not
a quest to elicit some objective factual truth — ‘what really happened’; rather, the play
therapist works with the subjective meanings that the child has made of their experi-
ences and the feelings generated - meanings and feelings which are made manifest
in their play and responded to by the therapist in the same metaphorical mode. “The
therapist acknowledges that the child has had life events which might need some sort-
ing and the play will not be to talk about these experiences but to make up stories in
which the characters might have had the same thing happen to them as have happened
to the child’ (Cattanach, 1997: 11).
The plots, themes and storylines the child creates may indeed have links to real world
experiences, but the play therapist will not interpret back to the child along the lines of:
‘I see — what you really meant in that story was that the dragon is your stepfather and
you are like that hedgehog, but will instead work safely and playfully with the meta-
phors the child has chosen, for example: “That tiny hedgehog is so scared of that huge
dragon when he roars fire! He has to curl up in a little ball to try and make sure the
dragon won't see him. I wonder if he hopes that might keep him safe?’ etc. The child is
thus enabled to explore feelings and experiences, make sense of them and cope better
thereafter, without it ever being made explicit that the story is ‘really’ about them and
 Play Therapy 99

their lives. Indeed, a critical assumption for play therapy is that therapeutic change
may occur without a conscious awareness of the association between the life experi-
ences that relate to the child’s difficulties and the symbolic manner in which these are
expressed. Dighton (2001) proposed that this therapeutic process enables children to
alter their perspectives on their life experience - what he termed ‘first order changes’ -
and, furthermore, that these may translate into changes of behaviour, cognition, affect
and attitudes (‘second order changes’).
Since play therapy uses the child’s natural ‘language’ — play — the level of sophistica-
tion of this language will reflect the child’s age and developmental stage. A typical play
therapy session with a 3-year-old will inevitably be rather different from that with a
13-year-old — although the teenager may very well need to regress back to missed earlier
play experiences, so there may also be many similarities! Jennings (1994) proposed
a continuum along which children’s play may be described: the earliest type of play
(both in normal childhood development and as featuring in a play therapy session) is
‘embodiment play’ whereby the child explores the world through their senses and in
which their own physical being is central. Sensory or embodiment play allows the child
literally to ‘get in touch with’ their physical selves, to differentiate what is ‘me’ and ‘not
me, to get a sense of what they like and dislike on the sensory level as a prerequisite to
being able to understand and express their emotional feelings. Sensory play taps into
primitive parts of the brain accessing pre-verbal experiences. All too many children
who come to play therapy have not had adequate embodiment play opportunities and
the chance to indulge in regressive sensory play: running their hands through wet sand,
poking holes in soft clay, exploring the ‘puerile’ delight of slime and fart putty can be
liberating and cathartic - and provide an awareness of the bodily self perhaps hitherto
suppressed or undeveloped.
The next stage on Jennings’ continuum is that of projective play - when objects (the
toys or play materials) and images take on metaphorical significance as the child pro-
jects meaning onto them: a simple stick can be a sword, a magic wand or a fishing rod,
and symbolic potential is limited only by the child’s imagination. In projective play the
child makes use of objects other than their own bodies to externalise their inner worlds.
Finally, in role-play, the last stage on Jennings’ continuum, the child — and often
the therapist too, at the child’s invitation - assumes roles within dramatisations which
may also be metaphorically rich. In dramatic play the child takes on roles in stories
from texts or through improvisation, and may involve the play therapist in the scene.
Dramatic role-play gives permission to do things that in everyday life would not be
permissible or ‘socially acceptable.
Working therapeutically with young people in a school context, elements of all three
play types may well feature: the young person may feel more comfortable in one play
mode but it is likely that there will be movement back and forth along the continuum
as the intervention progresses.
100 The Handbook of Counselling Children & Young People

Play Therapy: History, Background and Context

The use of play in therapy was pioneered in the field of child psychotherapy in the
early 20th century. Anna Freud (1928) and Melanie Klein (1932) were among those
who proposed a theoretical premise for the use of play. Freud used play to maximise
the child’s ability to form a ‘therapeutic alliance’ with the therapist, introducing games,
toys and magic tricks to interest the child patient in the therapy and in the therapist.
Klein claimed that a child’s spontaneous play was a direct substitute for the free associa-
tion used within adult psychoanalysis. Whilst theories and practice surrounding play
differ within each child psychotherapy tradition, they share the common central prop-
osition that play communicates the child’s unconscious experiences, desires, thoughts
and emotions. However, it could be argued that these analytical approaches use the
medium of play to indicate the source of the problem, rather than viewing play as a
curative or healing factor itself.
Whilst play therapy emerged from these elements of child psychotherapy, its specific
theoretical foundation owes much to the work of Carl Rogers (1951), who established
a new model of psychotherapy - client-centred therapy (later termed person-centred
therapy), a humanistic psychology tradition born out of a protest against the diagnos-
tic, prescriptive perspectives of his time. Rogers emphasised a relationship between
therapist and client based upon genuineness, acceptance (or unconditional positive
regard) and trust (see Chapter 2 for further details).
Influenced by this person-centred approach, Virginia Axline (1989 [1969]) developed
a new and succinct therapeutic approach for working with children - non-directive
play therapy (NDPT). Like client-centred counselling, NDPT holds a central hypoth-
esis of the individual's innate capacity for growth and self-direction and a belief in the
child as the chief agent in his/her own therapy. Axline’s eight principles, which empha-
sise the core importance of a warm, accepting relationship, underpin the work of most
play therapists today.
American play therapists such as Moustakas (1953), Schaefer (1979) and Landreth
(2002) progressed Axline’s formulations and devised differing models, integrating
elements of systemic family therapy, narrative therapy, solution-focused therapy and
cognitive behavioural therapy. One of the most significant developments has been an
increasing emphasis on the role of the environment in the formation of children’s per-
sonality and mental/emotional health and, pivotal within this, the role of attachment.
Recent advances in neuroscience have also informed the theoretical and clinical
development of play therapy: the more that is understood about how early experiences
shape and impact on brain structures and neural functioning, the better play thera-
pists are able to comprehend resulting behaviour and to demonstrate the importance
and efficacy of early interventions. Of particular fascination to play therapists practis-
ing today are enhanced insights into the neuropsychology of attachment and trauma
 PlayTherapy 101

such as Perry’s (2001) findings that children raised in environments characterised by

domestic violence, physical abuse or other persistent traumas develop an overly active
midbrain/brainstem, resulting in an over-reactive stress response and predisposition to
impulsiveness and aggression. Such evidence confirms that therapy must do more than
talk if the child is in a persistent hyper-arousal state, for the child’s brain may well be
unresponsive to verbal interactions. In order to heal a ‘damaged’ brain, interventions
must activate those portions of the brain that have been impacted.
Play therapy is now increasingly available in clinical and statutory settings in the UK,
for example within CAMHS (Child and Adolescent Mental Health Services), bereave-
ment organisations, ‘looked-after children’ teams of social services departments and
in the voluntary sector. Whilst several charitable organisations offer packages of play
therapy to clusters of local authority schools, it is still relatively rare for a referral to
be funded by schools themselves. However, it is common for a play therapist to work
with a child on school premises. At present this is predominantly within the primary
school age range, but play therapists do work in secondary school settings too — partic-
ularly, perhaps, EBD (emotional and behavioural difficulties) schools or in specialised
units within mainstream schools. One of play therapy’s strengths is its universality: the
approach can be adapted to suit different developmental levels and is appropriate for
children of all ages, and those from different cultures, genders and abilities. Play thera-
pists generally work with individual children, but some have experience of working
with groups and with siblings.
Play therapy is an effective intervention for children with a variety of presenting
problems and childhood difficulties (Bratton et al., 2005; BAPT, 2009). These include
children:

e who have been abused: physically, sexually or emotionally

e who have experienced loss through bereavement, family breakdown or separation from
culture of origin
e whoare terminally ill or disabled, or who cope with carers or siblings with disabilities or
illness
e who have witnessed violence or the abuse of substances
e whoare displaying behaviour that is regarded as a problem by those who care for them:
they may be difficult to control, withdrawn or not reaching their potential
e who externalise their difficulties with antisocial, aggressive, bullying behaviours
e who internalise their problems: the often-overlooked victims, prone to low self-esteem,
anxiety, depression or self-harm.

LeBlanc and Ritchie (2001) conducted a meta-analysis of 42 research studies of play

therapy which demonstrated that it is also a viable intervention for children with vari-
ous additional emotional and physical needs. Further evidence has demonstrated play
therapy is effective in a number of areas, including: prevention programmes (medical);
102 The Handbook of Counselling Children & Young People

conduct disorder (Davenport and Bourgeois, 2008); oppositional/defiant disorders;

social skills problems; sexual behaviour problems (Ciottone and Madonna, 1996);
attachment disorders (Ryan, 2004); and children in divorce. Other research points to
probable efficacy in prevention programmes (early childhood mental health); with
children experiencing peer relationship problems; chronic illness (Jones and Landreth,
2002); anxiety; separation and loss; fears and phobias; PTSD (Ogawa, 2004; Ryan and
Needham, 2001); witnesses to domestic violence (Kot et al., 1998); sexual, emotional
and physical abuse (Scott et al., 2003); ADHD; and with autistic spectrum disorders
(Josefi and Ryan, 2004).

Play Therapy Theory and Application to Practice

The format of exploration of the child’s difficulties is determined by a variety of factors,

including the child’s needs, the therapist's theoretical perspective and their work set-
ting. Most play therapists adhere to child-centred principles in that the child is given
significant choices about how to use the time and the play materials, but there is a con-
tinuum from pure non-directive approaches to more focused techniques.
Non-directive play therapists abide by the humanistic principles prescribed by Axline
(1989 [1969]) and emphasise the child’s ability to choose those materials which make
most sense to him or her, and to utilise the play experience and therapeutic relationship
in their own way and in their own time: the child is in control of the process and directs
the agenda, focus and timing. The non-directive play therapist follows the child’s lead,
verbally tracking what they are doing, acknowledging non-judgementally the choices
they make and voicing ongoing empathic reflections of the feelings they convey. A core
aim of the non-directive play therapist is simply to ‘be with’ the child (Landreth, 2002)
and to provide the optimum conditions that allow the child to develop their inherent
potential.
Some play therapists take a somewhat more prescriptive approach, using focused
techniques with defined goals in which it is the therapist who formulates the agenda,
with greater emphasis on ‘doing’ than ‘being’ Therapist-directed interventions influ-
enced by structured approaches, such as cognitive-behavioural therapy, have specific
aims such as helping bereaved children to explore grief and loss, or aggressive young
people to manage their anger.
In the middle of this continuum fall play therapists who follow a more eclectic or
collaborative approach, utilising both non-directive and directive methods, allowing
the child and therapist equal power to direct the agenda, focus and timing of the play
therapy. Cattanach (1997), for example, advocated storytelling techniques in the co-
creation or ‘co-construction’ of a narrative of the child’s experiences that evolves in the
interaction between therapist and child.
 Play Therapy 103

Central to all play therapy approaches, however, is the relationship between therapist
and child. The development of a constructive, trusting therapeutic relationship is a vital
component of the play therapy process.
In any play therapy intervention, the efficacy and legacy of the work with the child
client will depend greatly on liaison with parents/carers and on important inter-profes-
sional communication. A child does not exist in isolation - the family and social systems
in which they live and function can compound or perpetuate their difficulties, and if
significant adults in the child’s life are supportive of the play therapy, the child is more
likely to engage. The work has a better prognosis when there is a sense of team commit-
ment. Most play therapists will therefore meet with key adults such as parents, teachers,
social workers and learning mentors to gather a thorough understanding of the child’s
background and needs from their varied perspectives before commencing therapy and
will maintain this relationship via regular review meetings throughout the interven-
tion. Whilst adherence to client confidentiality is imperative, insights can be shared and
advice given which can help to shift others’ perspectives too and extend the benefits.

Play Therapy in Schools and Brief Play Therapy

Whether the approach is non-directive, directive or collaborative, many factors may

be involved in the decision for brief or longer-term play therapy to happen in a school
setting. The security of the familiar could be important for a young person who may
be intimidated by being taken to a clinic or strange venue. It is less disruptive to be
removed from one room to another for an hour than to leave school early or arrive late,
or to have an extra two-way journey during the day. Perhaps the child’s home is not an
appropriate place to work —- maybe through lack of confidentiality or space, or the need
for a more emotionally neutral setting. Some children receiving play therapy may be
in transition from the birth family to a foster or adoptive placement, so that the school
environment may be a key element of consistency.
Play therapists will commence their intervention with a careful assessment, building
up a comprehensive profile of the child, their early history, family background, and the
nature of the difficulties as perceived by others as well as by the child him/herself. When
working in school contexts the play therapist may require several referral meetings with
staff and parents/carers and ask for access to reports and existing assessments before
actually introducing themselves to the child. This assessment process, which begins at
referral, does not stop once the clinical work begins but is ongoing, with speculations
and hypotheses remaining open to re-evaluation as the therapeutic relationship develops.
It is crucial that the room where the therapeutic work takes place is free of inter-
ruptions. It can be immensely disruptive to a child in the middle of a session to have a
teacher enter to retrieve forgotten resources or for another child to burst in and wonder
104 The Handbook of Counselling Children & Young People

curiously what is going on. It need not be large or have any existing equipment — peri-
patetic play therapists will usually bring their own play materials. Some will also bring
a mat as a wipeable playing surface which both minimises the impact of any mess and
defines the therapeutic space, differentiating it from the room as it is normally used.
Access to a sink is an advantage, especially when several children are seen in succession.
The selection of toys and play materials should facilitate children’s expression by pro-
viding a wide range of play activities at their developmental level. These may include:

Toys for sensory/embodiment play: A sand tray (and water), clay, playdough, slimes, putties,
bubbles, assorted stretchy and tactile balls, etc.

Toys for projected/symbolic play: A dolls house, miniature human figures (various ages and
ethnicities), hero and monster figures, toy soldiers, cars and other vehicles, animal families,
miniatures of current popular film and TV characters (it is important to keep abreast of
trends), etc.

Real life toys for role-play: Dressing-up clothes, realistic dolls and baby accessories, puppets,
masks, pretend food, toy ‘weaponry’ play mobile phones, doctor's kit, etc.

Toys for creative expression: Paper, paints, finger-paints, felt-tip pens, crayons, chalk, col-
lage materials, glues, scissors and sticky tape, percussion musical instruments, etc.

These lists are not exhaustive and the range of equipment may be conditional on storage/
transportation factors.
The security of a predictable, consistent time for the play therapy session aids the
development of therapeutic trust. It is also imperative that all appropriate members of
school staff are apprised of the nature of the work and understand that attendance at
play therapy is not conditional on good behaviour. The misconception that play ther-
apy is a treat and that when a child has misbehaved in class they do not ‘deserve’ to have
this ‘reward’ can be hugely counterproductive.
Once initial assessments have been undertaken and practical logistics organised, the
play therapist will meet the child for the first time. Depending on the context of the
referral, and on the young person's age and level of cognitive understanding, it may be
supportive for a key adult to be present at this first meeting. For some children knowing
that significant adults in their life endorse the idea of play therapy can be most positive.
For others, of course, it may be quite the reverse!
It is critical that the child knows why they are there, so some discussion about the
reason for play therapy needs to be addressed at an age-appropriate level. It is impor-
tant to emphasise that the referral has not been made because the young person is ‘in
trouble’ — if it is perceived as a punishment then the intervention is tarnished from the
outset. Naturally the request for play therapy may be linked to a prevalence of ‘unaccep-
table behaviour’ in school or at home, but the play therapist will need to stress that the
therapeutic support is to help the child with the feelings that underlie the behaviour.
 Play Therapy 105

To reduce the negative perception that the referral is to meet an adult behaviour
modification agenda, it is helpful to get a sense from the young person themselves of
what they hope for from the therapeutic support.
Early sessions may well involve some limit-challenging as the child tests out the
boundaries that the play therapist has outlined. Equally, many young clients are scepti-
cal about the confidential nature of the therapy, and this is another aspect of the play
therapist's credibility and trustworthiness that may be questioned and challenged. A
young person whose previous relationships with adults have been characterised by
negativity, abuse, inconsistency or punitive criticism, will have developed an ‘internal
working model’ (Bowlby, 1969) to expect the same from all relationships, so establish-
ing and consolidating therapeutic trust may take several weeks.
The expectation for child-centred play therapy is that, through the play therapist's con-
sistent, empathic acceptance and respectful reflections, the young person will develop
self-respect and self-acceptance, and that improved self-esteem and capacity for self-regu-
lation will generalise to outside the play therapy space. Ongoing liaison with key adults in
the child’s life will help determine when the therapeutic goals have been met sufficiently
to close the work. Endings must be carefully planned: many young people will have
experienced these as traumatically abrupt in the past, so preparation for the end of play
therapy must be sensitively managed. The efficacy of the play therapy intervention can
be ascertained by qualitative or quantitative outcome measures, and reports provided.
The requirement for brief working tends to be more budget-driven and thus more goal-
orientated and the pressure to prove efficacy is increasingly acute in such contexts.

aes.
Case Study Elijah
Elijah was 10 years old at referral. Concerns from infancy about his speech and language develop-
ment had led to a Statement of Special Educational Needs which ensured ongoing in-class learning
support. He struggled to make sense oflessons, did not cooperate with teachers and found social sit-
uations, e.g. playtime, difficult to manage. His emotional well-being was connected to contexts that
he found challenging to interpret: his responses could appear impulsive and unpredictable so that
interactions with peers often escalated to conflict. He would sometimes express his frustration in
screaming and lashing out and often labelled himself negatively: ‘I’m really bad’ Elijah’s mother told
me he occasionally ‘zoned out’ when overwhelmed and that he had obsessive ‘specialist interests’—
then predominantly basketball. Whilst there had been no formal diagnosis, there was an unvoiced
implication in these behaviour patterns that Elijah might be on the autistic spectrum and there was
heightened concern about his impending transition to secondary school. Play therapy was intro-
duced with the aim of increasing emotional stability and coping strategies, and thus decreasing
inappropriate behaviour. It was envisaged that it would also improve understanding of self and

(Continued)
==
 106 The Handbook of Counselling Children & Young People

(Continued)

others (especially around feelings and the link to behaviour), thus building empathy, and would
strengthen his self-esteem.
At the introductory meeting in the presence of his mother and the SENCo, Elijah was initially
subdued and chose to lie on the floor rather than sit on a chair - |joined him there, which imme-
diately helped put him at ease. He listened attentively while | explained the reasons for play
therapy. He was particularly fascinated by the sensory materials and spontaneously involved us
by showing his discoveries. | drew attention to his reactions, and to those of his mother and
teacher where these might differ from his own: he was able to guess that Mummy would think
the slime was ‘disgusting’ whereas he was enthralled by it, suggestive of an unexpected potential
capacity for empathy.
In the first session alone with me, Elijah asked many interested questions in an evident bid
to build a relationship. He also showed a surprising facility for dramatised role-play: playdough
became a delicious pizza which he invited me to share. Whilst we carefully clarified that this was all
pretend — ‘Don't eat it for reall’— Elijah’s ability to initiate and sustain an imaginative mime required
an awareness of‘other ways of being’ and an understanding of non-literal meaning, which ran coun-
ter to the suspected ASD label.
As the intervention progressed Elijah blossomed. Whilst obviously hampered by language-pro-
cessing difficulties, he seemed desperately needy to engage with other people, greeting me each
week with garrulous enthusiasm. He soon began drawing, and the metaphors in his prolific and
skilful cartoons of basketball players in action provided rich therapeutic material. Themes of compe-
tition and rivalry, of fairness and unfairness, of triumph and failure, of pride and shame/despair were
all vividly symbolised in his basketball imagery. Later the drawings broadened out to enactments of
imaginative scenes — he role-played post-match interviewers, jubilant winners and despairing los-
ers, describing their supposed emotions in powerful language. He was even able to understand the
inherently contradictory concept of sarcasm, which had been the trigger of many a playground dis-
pute in the past.
After six sessions, teachers reported that Elijah had started to behave more like his peers and that
he was better at completing educational tasks. Towards the end of the second term there were no
further incidents of being sent’on referral’and he had been able to stay calm throughout his Year 6
SATS tests.
The focus of my work shifted towards preparing Elijah for the move to secondary school - having
been at the same school since nursery, this was a major transition so a specially devised statement
included the provision of ongoing play therapy in the new educational context. Written reports and
advance liaison with the new school facilitated this.
As the end of his primary schooling loomed, Elijah’s mixed feelings of excitement and fear were
expressed in the metaphors of basketball players preparing to transfer to different teams for the
new season: what would their new coach and team-mates be like? Would they like the huge training
facilities? Elijah’s basketball players conceded that their feelings might change as they familiarised
themselves with the new environment. By addressing this apprehension and ambivalence within the
 PlayTherapy 107

safety of play therapy, Elijah coped with it in reality - in the event, the loss of all his primary school
friends and surroundings was not as traumatic as many had anticipated.
After one term at secondary school, feedback was so positive that just five further fortnightly ses-
sions were scheduled. At the final review the SENCo reported: ‘We are pleased with his progress. Elijah
is a popular member of the class and staff report he is pleasant and attempts work set. He interacts
appropriately with his peers and has a good sense of humour. He is functioning well and has had no
detentions: Elijah’s mother was grateful: play therapy had helped her son understand his own and
others’ feelings and had enhanced his self-esteem. My empathic reflections, unconditional acceptance
and playful, empowering child-led approach were held to have been key mechanisms of change. Play
therapy also highlighted the potential for Elijah to develop further in his social competence than early
apo had implied and thus facilitated his adjustment into secondary school life.

Summary

e This chapter has summarised the historical development of play therapy in the United
Kingdom, tracing its theoretical underpinnings and evidence base
e Acontinuum of play therapy approaches was described, from non-directive to therapist-directed,
stressing that in all a trusting therapeutic relationship is as crucial as the play itself, as is appropri-
ate recognition and involvement ofthe wider system in which the child lives
e Some practicalities of setting up play therapy in a school setting were outlined, including the
environment and selection of appropriate resources
e A detailed case study, based on real client material (anonymised to protect the identity of
the client), illustrated a fairly typical process and progress of a young person receiving play
therapy in school, bridging the transition from primary to secondary education

Reflective Questions

1 Non-directive play therapists need to be unconditionally

accepting of the young person — why do you think this is
important and what obstacles within a school context might
there be for you in achieving this non-judgemental attitude?

Rogers (1951) argues that if the person can feel fully accepted, constructive personality
change will occur. Unconditional positive regard (UPR) may feel difficult to offer in a
school setting because we are used to judging children and young people in terms of
108 The Handbook of Counselling Children & Young People

achievement and behaviour, so UPR would feel contrary to the prevailing culture. We
need to consciously resist the ingrained adult inclination to praise a child for “being
good’ and saying ‘nice things’ and instead allow them to voice negative, potentially
shameful feelings without fear of judgement or criticism.

2 Whilst play therapy is relatively free of‘rules’, unlike much of

the school environment, there are certain boundaries that do need
to be in place — what is thejustification for this and what limits
might you establish?

Limit-setting ensures a safe and secure environment for children — indeed a child can
feel scared if left totally ‘free. Clear boundaries also reduce anxiety for the play ther-
apist. Limits structure, teach self-control and self-responsibility, serve to protect the
child, the therapist, the toys and the room and also help to minimise socially unac-
ceptable behaviour (whilst still demonstrating acknowledgement and acceptance of the
feelings that may underlie this behaviour). Whilst there are individual variations in
approaches to limit-setting, most play therapists clarify that children are not permitted
to hurt themselves or the therapist and that the toys and the room are not damaged on
purpose. Adherence to time limits is also important.

3 If children are deprived of opportunities for self-directed play,

what impact do you think this may have on their creativity, self-
confidence and capacity to relate to others?

Childhood play that is self-directed can lead to self-assurance, mastery and creative
problem-solving skills. Children whose play is limited to interactions with equipment
where there is a ‘right’ way to complete specified tasks and where opportunities for
meaningful social relationships are negligible, may grow up lacking the capacity to
think for themselves.

4 What long-term value do you think there may be in messy play

and in role-play?

Children who have restricted messy play opportunities may remain disconnected from
their physical selves and may become more inhibited in creative or physical self-expression
 Play Therapy 109

in later life. Those who engage in lots of pretend role-play may be better able to manage
different adult roles with more confidence.

pe ere a a ee ee geen a) a a ee eS
.
i] Learning Activities
|

I 4. Think back to your own earliest play memories: what do you recall that was especially
pleasurable or significant in your childhood play experiences? Consider the type of play
' you remember most fondly — was it messy or orderly? Creative/imaginative or struc-
1 tured and rule-bound? Solitary or with peers/siblings or in a team? Contemplate how
i this play has influenced how you behave as an adult.
yj 2. Rediscover your ‘inner child’ and nurture your own playfulness: inspired by activity 1, do
1 something playful or creative that you have not made time to enjoy for too long. It is
1 important that play therapists are comfortable with all types of play so maybe also try
i something new - and relish the excuse to get messy!
| 3. Observe a group of young children at play — note who takes the initiative and how the
i game evolves. Do the boys play differently to the girls? What happens in a mixed gender
y group? Consider how power and status are negotiated through play and how peer rela-
! tionships are developed.
4. Practise your tracking skills: watch a television programme with the sound muted and
1 give a running commentary of the key action you see. Label the emotions you can per-
1 ceive in the facial expressions and body language ofthe actors.
yj 5. Gotoa charity shop or car boot sale and build up your collection of small toys and play
rl resources: other people's discarded ‘junk’ can be a play therapist's treasure trove!
s
eS SS Sea ae eee Se See See Oe Cs eee

Further Reading

The following core texts elaborate on some of the theoretical underpinnings to play therapy out-
lined in the sections above and will enhance and deepen understanding ofthis clinical approach
and the contexts in which it is practised

Axline, V.M. (1990 [1971]) Dibs in Search ofSelf. London: Penguin Books.
Carroll, J. (1998) Introduction to Therapeutic Play. Oxford: Blackwell Science.
Cattanach, A. (2003) Introduction to Play Therapy. Hove: Brunner-Routledge.

(Continued)
110 The Handbook of Counselling Children & Young People

(Continued)

Cochran, N.H., Nordling, W.J. and Cochran, J.L. (2010) Child-Centred Play Therapy: APractical Guide
to Developing Therapeutic Relationships with Children. New York: John Wiley & Sons.
McMahon, L. (2009) The Handbook of Play Therapy and Therapeutic Play. 2nd edn. East Sussex:
Routledge.
Schaefer, C.E. and O’Connor, K.J. (eds) (1983) Handbook ofPlay Therapy. New York: John Wiley &
Sons.
Van Fleet, R., Sywulak, A.E. and Sniscak, C.C. (2010) Child Centered Play Therapy. New York: The
Guilford Press.
West, J. (1996) Child Centred Play Therapy. 2nd edn. London: Arnold.
Wilson, K., Kendrick, P. and Ryan, V. (2001) Play Therapy: ANon-Directive Approach for Children and
Adolescents. London: Bailliere Tindall.
Woolf, A. and Austin, D. (2008) Handbook of Therapeutic Play in Schools. Chester: A2C Press.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com.
BAPT (British Association of Play Therapists) Play Therapy in Action. Available at: www.bapt.info/
trainingdvd.html. This is a 3-minute clip of play therapy and the page has links that will enable
you to order the whole DVD, more than 2 hours in length.
 Other Creative Approaches
Barbara Smith, Kaye Richards and Toby
Quibell

This chapter includes:

e Anumber of creative approaches that can be integrated into counselling and psychotherapy
practices, many of which have longstanding traditions and are underpinned by a wide range
of theoretical perspectives and have been developed over many years
e An insight into alternative ways of engaging children and young people in counselling and
psychotherapy with the integrated use of creativity. This will draw upon the experience of
the authors who use a range of modalities (person-centred, transactional analysis, and cogni-
tive-behavioural therapy) and creative approaches (drama, sand-play, outdoor adventure, art,
clay-work, music, dance, etc.)
e Case study material to illustrate creative working in action, to serve as a reminder that some-
times talking alone isn’t always enough
e Questions and activities for exploration and discussion

Elsewhere in this book are valuable accounts of important issues of ethics, boundaries
and the law, as well as other significant aspects of working with young people. It is not
the intention to include these concerns here, but instead to explore the practical matter of
helping children and young people to open up through a variety of creative and ‘alter-
native’ methods. In examining creative ways of working, this chapter will by no means
be an exhaustive account of these approaches, and some are covered in more detail in
other parts of the book.
112 The Handbook of Counselling Children & Young People

Introduction

Even a minor event in the life ofa child is an event ofthat child’s world and thus a world
event.
Gaston Bachelard (1884-1962)

Being allowed into the world of a child or young person is a privilege and an adventure.
Every encounter provides an opportunity for healing: every smile; every greeting; each
time we laugh at a child’s humour; sharing aspects of our own experience; and offering
a safe space in which to explore past experiences and worries goes a little way to heal-
ing the hurts that bring them into therapy. As adults, we often focus on the ‘problems’
that children bring: trauma, bereavement and other transitions; the effects of bullying,
depression and all manner of anxious states (Bailey and Shooter, 2009). In this chapter,
as well as acknowledging children’s distress, we want to also highlight the strengths that
children and young people bring: resilience; power; humour; imagination; experience
and creative possibilities that help them to overcome difficult life experiences or worries.
The title of a recent strategic plan supporting the government’s ‘No health without
mental health agenda is Talking Therapies: A Four-Year Plan of Action (DoH, 2011).
Such a title clearly indicates a preference for therapies which use language as a central
construct to address the various issues that children and young people bring to therapy.
This chapter offers alternatives to solely talking; indeed, many of the young people that
the authors have worked with have been unable or unwilling to express themselves in
the more traditional verbal way.
Creative work is particularly relevant when working with children and young people.
Axline (1947) believed that because they express themselves through play, it is a natural
therapeutic medium for children. As a student of Rogers’ person-centred approach,
she saw that the child would direct the play in a way that is productive in helping them
to work through their struggles. Children dealing with particular issues will ‘play out’
what they can't ‘talk out’ about difficult life events (e.g. parental separation, conflict and
bereavement), enabling them to resolve issues that they cannot express through words.
Malchiodi (2005) distinguishes between those therapists who have in-depth training
in various creative therapies and those who integrate expressive therapies into their
psychotherapy work. This chapter focuses on the latter group, in that it introduces ideas
that have been successfully integrated into the authors’ own practice, and in doing so
is not offering a detailed examination of specific creative therapies, such as art, drama
and dance therapy. Carson and Becker (2004), however, refer to ‘creativity in counsel-
ling, describing the therapist's willingness to respond in a flexible and creative way,
attuning to client's creative possibilities. It is hoped this chapter explores, therefore, the
broader creative potential of therapeutic practice.
Some creative approaches are more readily available for the everyday therapist (e.g.
art and creative writing), whereas others require more specialist skills (e.g. outdoor
 Other Creative Approaches 113

adventure therapy). That said, as pointed out by Malchiodi (2005: 6), when using crea-
tive therapies to complement other psychotherapy theories we should ‘be mindful of
the current standards of practice in the particular modality [we] are using. So it is
important to refer to the list of relevant professional bodies and organisations to find
those related to the approaches discussed here. And of course the old maxim of ‘never
ask a client to do what you wouldnt do yourself’ applies in creative therapies. At the
end of the chapter there are a number of simple exercises to encourage the reader to
explore some of the creative themes addressed.

Taking Creativity into Therapeutic Practice

The value of creativity in the therapeutic process is not a new phenomenon; McNiff
(1981) discusses the use of art in healing throughout the ages and Malchiodi (2005)
builds on this, highlighting how artistic activity was used in ancient Egypt to help people
with mental illness. She describes how the Greeks used drama and music for healing,
and how Goodenough (1926) was analysing children’s drawings early in the last cen-
tury. In 1939 Margaret Lowenfeld developed the ‘Lowenfeld World Technique’ from
her work with sand trays, toys and models. The children Lowenfeld worked with called
her ‘wonder box’ of play materials ‘the world’ and started to create scenes and worlds
in the sand box in her playroom (Lowenfeld, 1993). Alongside this, dance therapy can
be traced back to the 1930s with dance teacher Marian Chace (see Sandel et al., 1993).
She encouraged her students to express their emotions through dancing. Local doctors,
seeing the benefits of the approach, started sending patients to her classes. Founded on
the assumption that movement and emotion are directly related, the principle behind
dance and movement therapy is to find a sense of wholeness and balance (Payne, 2006).
The use of creative therapies is increasing its standing in the statutory mental health
field. In 2009 the National Institute for Health and Clinical Excellence (NICE) recom-
mended that art therapy be considered as a supplement to standard care in patients
with schizophrenia, and Crawford and Patterson (2007) highlight the emerging evi-
dence base for using arts therapies for people with schizophrenia. A systematic scoping
review undertaken by Harris and Pattison (2004) revealed a range of evidence-based
studies supporting the use of creative therapies with children and young people: group
drama therapy for children with behavioural and emotional problems in the school
setting (McArdle et al., 2002), group work and role-play for improving levels of act-
ing out, distractibility and sociability with learning-disabled children (Omizo and
Omizo, 1987), humanistic play therapy effective in reducing anxiety in children whose
parents have divorced (Dearden, 1998) and play therapy to reduce anxiety and build
self-esteem and cognitive skills in schoolchildren (Sherr and Sterne, 1999). What fol-
lows are illustrative case study examples of how, as authors, we have used creativity in
our therapeutic work with children and young people, employing a variety of media.
 114 The Handbook of Counselling Children & Young People

Working in the Sand Tray and Storytelling

Sand tray work is a creative and popular approach, especially in working with younger
children. The use of small toys and figures in sand tray work is highlighted by Geldard and
Geldard (2002). They describe a goal of sand tray work as giving children an opportunity
to tell their story with symbolism and metaphor, using model trees, fences, cars, soldiers,
heroes, dragons and animals. This enables the child to express fears and fantasies in the
small safe ‘world’ of the sand tray. Children use their imagination and subconscious to
create a microcosm of their inner world. Below is an example of sand tray work with “Tom.

x
Case Study Tom
Tom, aged 10, was in care and had been referred because of his withdrawn behaviours, enuresis and
occasional aggressive physical outbursts. He found it hard to regulate his feelings and would often
seem to be‘in a world of his own’- disconnected - and finding it difficult to express himself verbally.
He was significantly developmentally delayed in his speech, cognitively, and in his social and emo-
tional skills. Before meeting Tom | had read a comprehensive referral document detailing some of his
early experiences. It was heartbreaking to read. He and his siblings had been severely neglected from
an early age and he had taken a great deal of responsibility for his three young brothers and little
sister. He had been denied food, water and stimulation. He had also been physically and emotionally
abused by his stepfather. Tom had had a number of fostering placements.
Tom was invited to explore the play room and to choose what media he would like to use. He
loved the sand tray. He chose a variety of toys, including trees and wild animals. Over the weeks as he
played in the sand, his story of abuse and fear unfolded as the giraffe shouted at the monkey ‘Get in
there you’... ‘don’t you get out of that bed’... ‘stand there’ Other times animals would be buried deep
in the sand - ‘disappeared’ These scenes were played over and over until he moved onto another
theme from his difficult past.
During the early stages of our work together he had been told that he was moving to another
placement. While therapeutic work can be contra-indicative for a child who is not in a settled place-
ment, this was another unexpected twist in his troubled and unsettled life. Whilst waiting for his new
placement, Tom continued his sand tray work. One day he drew a line down the middle of the sand.
One side was his old life and one side was his new life. In exploring his old life, he made several pur-
poseful trips to the imaginary skip, throwing out all the ‘old stuff’ In his new life he created a veritable
little paradise, speaking about his hopes and expectations of his new placement.
While Tom never spoke verbally about his experiences prior to coming into care, he took the
opportunity, through the sand, to communicate his distressing feelings of fear and anger. Tom is
now thriving in his new placement; he is dry day and night, and expressing his thoughts and feelings
in more helpful ways within the nurture and care of a loving family.
 Other Creative Approaches 115

There are other ways in which therapists can be creative in enabling children to work
playfully and tell their stories. One author uses miniature plastic toy figures - Gogo’s
(also referred to as Crazy Bones) - in her storytelling with children. After discovering
Gogo’s by accident, she now keeps a collection of the tiny, brightly-coloured figures in
her therapy room. All have different colours and features, and the children and young
people are able to project their own characters onto the figures, sometimes telling sto-
ries about who lives in their house or who's who at school. They have been particularly
helpful in life story work for looked-after children, with each different household they
have lived in being portrayed by small groups of Gogo’s as the child’s story unfolds. The
popular little figures are immediately recognisable to the children and seem to be ‘of
their world: Children often leave with a handful of Gogo’s to represent qualities that they
have, e.g. ‘Choose one that fits with your being really kind. Now choose one that shows
how strong you are when you play football. Now choose one that shows your funny side?

Working with Art

Art is commonly used across a range of psychotherapies as a vehicle for self-expression

and understanding and can employ a variety of media. In a discussion of working
therapeutically with clay, Geldard and Geldard (2002) emphasise its pleasant texture
when ‘feeling, stroking, pressing, punching, squashing and shaping’. They highlight the
benefits of being able to change its shape, allowing the exploration and development
of emerging themes to symbolically express held-in feelings. Emotionally blocked chil-
dren are able to contact and express their feelings through working with clay. Sherwood
(2010) suggests that using clay in therapy provides therapists with a powerful medium
to help clients work through many core issues such as anger, grief and fear.

o >
Case Study Jess
Jess, a black child, aged five, was referred by her social worker after becoming ‘looked-after’ because her
mother’s partner had pushed her down the stairs. Other physical abuse became apparent during the
investigation, and despite the man being convicted of the assault, Jess's mum refused to acknowledge
the danger that he posed to her daughter.
Jess was placed with her maternal aunt but was distressed and confused about not living with her
mum. She was an anxious little girl who sometimes had distressing ‘outbursts’ where she was clearly
overwhelmed by her difficult feelings. Jess had no understanding of how to regulate her difficult
emotions.

is (Continued)
 116 The Handbook of Counselling Children & Young People

(Continued)

When Jess was invited to work with the clay, she built a fort with no doorway. She also built a
jail. In exploring the jail, she was able to talk about where the bad man went, whether he might
come and ‘get her’ and who would save her. Jess was expressing her fear of the man who abused
her and letting me know about her precarious sense of safety. We were able to explore who was
there to look after her (safe adults, police, social worker, the judge) and how the bad man would
have to learn his lesson in jail about how to be good. As the session progressed, Jess created a door
in the fort ‘for the people to get in and out’ (the jail stayed firmly locked). As Jess’s anxieties were
addressed, she was able to contemplate allowing others into her clay refuge and also to venture
outside.
During another session, Jess was talking about her life when she distractedly began to scrape
cobs ofclay up and down her little arms until her beautiful black skin was covered in the pale grey
clay. When | commented about it she said, ‘if |drink milk will the rest of my body be white like my
feet?’ This presented an opportunity to explore Jess's black identity, discovering how she related
to her blackness and how she coped with this in a largely white community. In addition to the
work in the therapy room, the work also presented the opportunity to support her aunt in devel-
oping a positive black identity. (For more on black identity see the work of Esther Ina-Egbe, 2010.)

y
Gestalt therapist Violet Oaklander (1997) talks of the endless possibilities for freeing
our creative process through drawing. She describes how the very act of drawing, even
with no therapist intervention, ‘is a powerful expression of self that helps establish one’s
self-identity and provides a way of expressing feelings’ (ibid.: 306). Whilst many chil-
dren enjoy messy play with clay, poster paints, etc., others enjoy the ordered world of
mandalas (see Figure 8.1).
Mandala is a Sanskrit word meaning ‘circle. Within Buddhism and Hinduism they
have spiritual and ritual significance. Some therapists have used mandalas to work with

Figure 8.1. Mandala images.

 Other Creative Approaches 117

young people and their teachers in the school setting for personal growth and relaxa-
tion. In a study by Curry and Kasser (2005), 84 undergraduate students, after having
a brief anxiety induction, were randomly assigned to colour a mandala, a plaid form,
or to colour on a blank piece of paper. They found that anxiety levels declined simi-
larly for the mandala and plaid colouring, and that both of these groups experienced
more anxiety reduction than the unstructured colouring group. The findings suggest
that structured colouring of quite complex geometric patterns may induce a meditative
state that benefits people with anxiety.

Poetry and Song Writing

In thinking about creative approaches, Oaklander (1997) makes use of storytelling and
poetry, as do Cattanach (1997) and Hedges (2005) in their therapeutic practice. The
National Association for Poetry Therapy (2014) tells of the first poetry therapist on
record, a Roman physician, Soranus, who practised in the first century AD. They iden-
tify how he prescribed tragedy for his manic patients and comedy for those who were
depressed. They also note how during the 17th century Dr Benjamin Rush, known as
the ‘father of American psychiatry, introduced poem writing to patients who went on
to publish their work in the hospital newspaper, The Illuminator (ibid.). One of the
authors of this chapter uses ‘bio-poems’ when training foster carers to work creatively
with looked-after children. These draw upon a child’s biography, and an example can
be seen in Table 8.1.

Table 8.1 An example of a‘bio-poem’

Bio-poem formulation A bio-poem example

Line 1 Your first name only Caitlin

Line 2 Four traits that describe you Petite, bubbly, happy and energetic,
Line 3 Sibling of ... (or son/daughter of) Sister of Gemma,
Line 4 Lover of ... (three people or ideas) Lover of gymnastics, chocolate and horses,
Line 5 Who feels ... (three items) Who feels happiness with friends, loneliness at night,
and joy at the gym,
Line 6 Who needs ... (three items) Who needs friends, love and acceptance,
Line 7 Who gives... (three items) Who gives friendship, love and encouragement,
Line 8 Who fears ... (three items) Who fears not winning, bullies and losing friends,
Line 9 Who would like to see ... (three items) | Who would like to see the world, Justin Bieber and
the summer holidays,
Line 10 Resident of (your town or street) Resident of Liverpool,
Line 11 Your last name only Jones
118 The Handbook of Counselling Children & Young People

Others highlight the role of song-writing therapeutically, for example in palliative

care (O'Callaghan, 1996), promoting pro-social behaviours in aggressive adolescent
boys (Rickson and Watkins, 2003) and reducing anxiety and distress in traumatised
children (Mayers, 1995). One author uses the notion of ‘boasting songs’ (a song-writing
pastime of adolescent Maasai girls in Kenya) in her work with young people. Drawing
on the concept of ‘strokes’ in transactional analysis, where we embrace other peoples
qualities and talents, as well as our own, she helps young clients to engage with and
highlight their attributes and potentials through the playful process of boasting songs.
This can be particularly helpful using rap music in group work with teens, as described
by Hadley and Yancy (2012).

Drama

In her work with ‘creative dramatics, Oaklander (1997: 298) describes how children,
when play-acting, ‘never actually leave themselves; they use more of themselves in
the improvisational experience’ A connection between drama and healing was pro-
posed by Aristotle, who coined the term ‘catharsis. While Aristotle never defined
this in his work (Poetics 335 BC), it has been interpreted by others as purgation,
purification and clarification (Aristotle, 1895). Essentially, drama therapy is a group
of action techniques (drama games, improvisation, masks, puppetry and role-play)
which helps with personal growth and behaviour change. Drama therapy is often
used in schools, and Schneider (2006) promotes the use of drama therapy with autis-
tic children to enhance self-confidence, not only in performing but in interactions.
She also suggests that the work increases children’s self-esteem, recognition of emo-
tions in others, skills for functioning as part of a group, and improved interaction
with other group members.
The provision of therapeutic interventions in schools is clearly a key agenda for
addressing the mental health of children and young people, as discussed in other
chapters. For example, School Counselling: The Action Group Skills Intervention
programme (McArdle et al., 2002, 2011), developed by one of the authors, is one of
many examples of integrating therapeutically-based drama approaches into interven-
tion work with young people. This approach specifically focuses on four areas of work
within a school setting (traumatised children, classroom situations and behaviours,
creative curricula and systemic change within the organisation), using drama to help
groups of young people in schools who are troubled and troublesome. It aims to help
children to recognise destructive patterns in their behaviour, and by reflecting on
their roots in social, emotional and behavioural habits, to change these patterns. It is
grounded in attachment theory, object-relations theory, and psychodynamic theory.
The intervention comprises creative-expressive (Jennings, 1992) or psychodrama
 Other Creative Approaches

(Moreno and Moreno, 1969) approaches, including role-play (Bolton and Heathcote,
1999), and using a range of dramatic techniques to either heighten the experience or
to contain it (Emunah, 1994).
All sessions begin with a ‘talking forum; an opportunity for each child to speak out
and be heard. The earlier sessions are characterised by co-operative and competitive
games, so that talk can focus on common themes or experiences within the group.
These also serve the purpose of creating a group identity, mutual trust and the setting
of boundaries for behaviour. The middle sessions use a range of self-expression and
controlled physical activity, as well as artistic work such as painting and mask-
making. Later sessions utilise the material from the expressive phase to create dramas,
enacted by the group for the group. The nature of the drama varies from group to group,
depending on their experience and the way each group approaches expressive materials.
For instance, a group might develop a fantasy play drama using predominantly their
mask work or real-life role-plays with children taking on the characters of figures
from their world. In the final phase, the sessions are characterised by reflection on
the learning and developmental points offered by the group experience and integration
of individual insights into ideas for behaviour outside the group.

Case Study A Brief Encounter

A smartly-dressed man sits alone in a circle of chairs waiting for eight Year 9 pupils. ‘Why is it always
Year 9?’ he wonders, feeling nervous and uncharitable. The door opens and he gets up to greet the
young men and women who crowd the room in all the glory of their ruckus and aftershave. As the
session progresses, the young people run through a practised repertoire of hormonally-fuelled
bonding and conflict behaviours, most of which are fielded by the smartly-dressed man, who works
hard to engage the noisy, energetic group in simple group games.
Using six-part story-making (Lahad, 1992) as a structure, we were working in a very cold room ina
portakabin and the group was not going well. Too many big characters with too much bravado and
too much knowing adolescence to let go and re-enter childhood. We were looking for a spark as the
group went through the motions, first drawing their stories and then sharing them. We had the idea
to make masks with card, each child making a mask relating to a character in their story — the young
people taking control of the creative process. We then put three seats out front and waited for them to
fill with children and their masks. It could go either way — my sense was that one of the young people
might put on a silly voice and mock the process.
Maria pulled the mask down over her face and took a ‘isn’t this a waste of time’ pose. She started
to talk and something amazing happened - she was speaking gobbledegook. It was wonderful. It
was like she had accidentally made a leap into hyperspace - she scarcely knew what was happening
herself. |grabbed a pencil sharpener from the desk behind me, pressed it into her hand and we spoke

(Continued)
 120 The Handbook of Counselling Children & Young People

(Continued)

into this ‘decoder’ We heard that she was alien to this planet and she did not understand any of its
rules. She was lonely, although she had learnt how to pass herself off as one of the crowd. Maria’s
body shape had changed, her breathing was full of attention, and we could almost feel the adrenalin
of hyper-awareness. The room was rapt and the magic began to happen.
At the end of the session one of the pack leaders begins the feedback. The man leans forward to
listen — ‘this is alright actually; because at first we thought you were some random banker’ The man
smiles in a friendly fashion and straightens his tie. He thinks he heard it right.

Creative Risk-Taking: Outdoor Adventure Therapy

There has been a long tradition of using outdoor adventure activities for the personal
and social development of young people (Hopkins and Putnam, 1993; Ogilvie, 2011).
The psychological and physical demands of outdoor and adventure settings are often
so different and so much more intense than those experienced in everyday life that
they offer psychological, sociological and physiological benefits (McCormick et al.,
2003). Research suggests that self-concept and self-esteem are key benefits of outdoor
programmes (Martin, 1983; Washburn, 1983) and recorded benefits for young peo-
ple include reducing problem behaviour (Pommier, 1994), reducing recidivism rates
(McNutt, 1994), increasing self-efficacy (Hughes, 1993) and improved social function-
ing of outdoor programme participants Gibson (cited in Gass, 1993: 44). Ewert (1989)
argues that outdoor activities can provide benefits to mental health, as an adjunct
to clinical therapeutic techniques, and this is evident in the treatment of addictions
and post-traumatic stress disorder (Ragsdale et al., 1996), substance abuse (Gass and
McPhee, 1990), survivors of sexual abuse (Pfirman, 1988), young offenders (Reddrop,
1997), problems with marital intimacy (Hickmon, 1993), eating disorders (Richards
et al., 2002) and psychiatric patients (Gilliam, 1990; Blanchard, 1993). So the range of
identified benefits has clearly been used for addressing a range of clinical and health
conditions and reflects the growing development of outdoor adventure therapy, with
approaches including wilderness therapy and nature-based therapies (Richards et al.,
2011). These developments are reflected in the regular international adventure therapy
conferences and related publications overseen by the International Adventure Therapy
Committee (see Itin, 1998; Richards and Smith, 2003; Bandroff and Newes, 2005;
Mitten and Itin, 2009; Pryor et al., 2012).
The elements of novelty and challenge are key ingredients that differentiate adventure
and wilderness therapy from more conventional experiential therapies. A young person's
perception of the risk involved may be such that they have an additional emotional level
 Other Creative Approaches 121

of arousal to manage. The key concept here is of inviting young people to step outside
their comfort zone and in so doing examine the experience they have of themselves, in
a new zone of disequilibrium (Gass, 1993). The significance of this novelty is that it pro-
vides clients with an opportunity to examine their pre-existing beliefs about themselves.
Gass (ibid.) describes this as ‘edge work’ It is largely a process-oriented approach based on
a number of assumptions about the process of therapeutic change. It holds the view that
clients may find it difficult to achieve change in the context of their normal everyday cir-
cumstances. In such settings, much in their lives and thinking will conspire to keep things
the same. Thus, if clients stay within their comfort zones change is unlikely. However, if
clients are facilitated to work at ‘the edge; or even step over the edge of their comfort zone,
then they are likely to experience, at best, new aspects of themselves and new ways of cop-
ing, or at least gain some insight into their habitual coping behaviour.
The role of risk-taking in the therapeutic agenda of young people has particular
significance. Geidd (2008) suggests that adolescence is a time of substantial neurobio-
logical and behavioural change. The behaviours that accompany these changes include
separation from family of origin, an increase in risk-taking and increased sensation
seeking. “These changes and the plasticity of the teen brain make adolescence a time
of great risk and great opportunity’ (Geidd, 2008: 341). Similarly, Hasset (2012: 70)
suggests that ‘increased risk-taking in adolescence is normative, biologically driven
and inevitable’. Speaking of the adaptive role of adolescence, he states that a biological
wedge is naturally driven between young people and their parents to aid transition to
independence. He also states that ‘you need to engage in high-risk behaviour to leave
your village and find a mate’ (ibid.: 72). Adventure therapy enables young people to
engage in creative risk-taking, allowing the experience of authenticity and subsequent
psychological change.

Case Study Danny

Danny, aged 14, had been diagnosed with ADHD some years ago and had had a troubled past. He was
being raised by his dad, his mum having died when he was eight. Since his mum’s death Danny had
become difficult to manage at school and at home. He had been referred for bereavement support
through his school counsellor, but did not return after the first session. He had begun to seriously
self-harm by cutting his arms, was hanging around with much older boys and was drinking alcohol
harmfully. He did not want to access the Child and Adolescent Mental Health Service (CAMHS), as is
common with young people who are at this level of risk. A range of professionals were trying to sup-
port Danny, and he was reluctantly placed in a single occupancy residential placement with ‘round
the clock’ care.

(Continued)
a yy
 122 The Handbook of Counselling Children & Young People

(Continued)

As the staff team began to win Danny's trust, he would talk to them about his mum and his
past, but he continued to harm himself and put himself at considerable risk in the community.
An offer was made to work on a one-to-one basis with Danny in the outdoors, and while ini-
tially giving a flat refusal, he was shown the website of the venue where the work would be
undertaken. This seemed to ‘hook’ Danny’s adventurous spirit. After meeting with Danny, it was
evident that there were areas that could possibly be impacted by the use of a variety of out-
door adventurous activity, including rock-climbing, mountaineering and high ropes courses.
The therapists agreed to offer opportunities to experience issues of ‘trust’, safe ‘risk-taking’ and
‘accepting support’.
Danny arrived at the outdoor venue and was introduced to the activities for the two days. The
first was a ropes course where we invited Danny to engage in a childlike way, quite different from
the moody adolescent facade we were used to. In the paradoxical experience of fear and excite-
ment, Danny showed his authentic feelings of enjoyment, unable to maintain the indifferent and
disconnected persona which had kept him ‘safe’ and others at bay for many years. As the outdoor
trainer and therapist worked together to enable Danny to express his feelings more openly, he
began to acknowledge his fears and uncertainty about the future. His sense of self-efficacy was
compromised due to his early life experiences. Offering him opportunities to experience his capa-
bilities was crucial in the outdoor adventure work.
Given this, the team decided to facilitate Danny on a mountainous rock climb to build a sense
of competence and resilience. At first Danny was doubtful about the task in hand — he had never
climbed roped on a mountain before; he felt unsure about his ability and anxiety about entering an
unknown environment.
This was the kind of risk Danny had never previously encountered. During the climb, a number of
pivotal moments occurred. As he became more confident in the climb, Danny began to connect more
openly with the therapists, sometimes offering support and even requesting support — something
that Danny had previously resisted. Importantly, he began to play, making Tarzan noises as he became
more relaxed and playful. Hearing Danny's laughter and Tarzan cry echoing across the mountains was
a joy for the therapists. Danny had resumed hisjourney.

Research Issues

The creative endeavour offers opportunities for therapists to engage with their
young clients on a range of levels and through a wide variety of media. Recently,
Cooper and McLeod (2010) presented the concept of pluralistic counselling and
 Other Creative Approaches 123

psychotherapy. Citing Lazarus’ (2005) multimodal approach, they suggest that dif-
ferent clients are helped by different methods. They also highlight the development
of practice which incorporates the whole range of concepts and therapeutic meth-
ods. Two key principles underpin the pluralistic approach: 1) lots of things can be
helpful to clients; and 2) if we want to know what is most likely to help clients,
we should talk to them about it (Cooper and McLeod, 2010: 6). Alongside this,
we need to also ensure that the relevant research agendas are developed in order
to examine the impacts and effectiveness of such work. The research priorities for
creative approaches obviously cross a wide range of priority areas of counselling and
psychotherapy research per se — too many to discuss here. However, the role of crea-
tive approaches for certain types of presenting client issues and the dynamic nature
of key aspects of the therapeutic process need consideration and raise challenging
research questions. For example, the changing dynamic of the therapeutic relation-
ship in an outdoor setting is one of many examples (Harper, 2009). As practitioners
we need to ensure we look to research findings to guide us on the application of
creative approaches in our work and also to understand more fully the potential of
these approaches for achieving longstanding psychological change.

Summary
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In conclusion, the key points for consideration when thinking about the role of creat ive approaches
for counselling and psychotherapy are:

1. Engaging young people means communicating in ways that they understand and enjoy. The
sensory nature of creative work supports this endeavour, enabling children and young people
to express their feelings in their own language
2. Having access to a broad range of creative media enhances therapeutic possibilities and gives
children a wider choice in how therapy is conducted
3. Employing creative media and techniques requires the therapist to be able to connect with
the symbolism and imaginative essence of the child’s world
4. Working creatively with children and young people teaches us how to re-conne ct with aspects
of ourselves perhaps long-forgotten

Finally, it is well documented that children and young people contact the world through play
and creativity — our task is to harness the therapeutic potential that these things bring and thus
embrace more of a pluralistic approach to our creative practices. In the words of Picasso, ‘Every
child is an artist — the problem is staying an artist when you grow up’
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124 The Handbook of Counselling Children & Young People

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Learning Activities

So now time to get creative yourself. The invitation is to simply take some time to do some
of the creative activities as highlighted in the chapter. As with any creative approach, the
goal is not to overthink it — just create a quiet space, gather the relevant resources and
allow yourself some creative time.

1. Writing a bio-poem: Write a bio-poem, following the format example in the text, about
a child you care about.
2. Creating a mandala: Sit quietly and breathe deeply. Ask yourself these questions: what
shapes do | like - curves, angles, circles, straight lines? What do | like in nature — trees,
water, animals, birds? What symbols do | like — light, dark, candles, flowers? Draw a circle
on a large sheet of paper. Choose a few colours to use — about four or five. Divide the
mandala intuitively into sections, e.g. your past, present, future, hopes, dreams, family,
friends, faith. Now let your mind wander and let the colours find their own way onto the
paper. Daydream. Be open to insights and new awareness. Access your own wisdom,
creativity, love, and truth and see what unfolds.
3. Mould clay to music: Letting your creativity flow in response to music can have a medi-
tative quality. Let your feelings out or just relax and enjoy the sensory experience of
moulding clay. See what textures, shapes and images emerge.
4. Go outdoors: Take a walk outside in a local green space area. As you walk, take notice of
natural things that you see — take time to look, sense, touch and smell these. As you do,
take notice of thoughts and feelings that these natural things stir in you. Do they pro-
vide symbols to you, do you notice metaphors that relate to you — feelings, dilemmas,
thoughts, hopes, etc.? After a short time find a suitable safe spot to sit down. Take time
to reflect more on your experience of nature,
jotdown thoughts, images, feelings, etc. If
you collected any natural things replace them after you have made some notes. Do the
same walk for a number of days or weeks. Allow your journey each time to unfold and
don't let rain deter you from going outside!
® s

Further Reading

Axline, V. (1947) Play Therapy. Boston: Houghton Miffin.

An older but nevertheless classic text for play therapy with children. Always good to read the key
foundational books, and this one certainly still stands strong today.
 Other Creative Approaches 125

Emunah, R. (1994) Acting for Real: Drama Therapy Process, Technique and Performance. London:
Brunner-Routledge.
This offers a good overview of the field, so will set the scene well for a range of key areas.

Karkou, V. (ed.) (2010) Art Therapies in Schools: Research and Practice. London: Jessica Kingsley.
This deals specifically with practice in schools, which helps to focus on approaches for young
people. It gives context to work in both mainstream and special schools, and across the different
art therapies (e.g. music, dance and art).

Gass, M.A., Gillis, H.L. and Russell, K.C. (2012) Adventure Therapy: Theory, Research and Practice.
London: Routledge.
Although it has a North American slant, this offers a good overview to key areas related to this
developing field, with good signposting for key ideas and literature.

For a wider overview of international practices and developments see the published texts from
each of the International Adventure Therapy Conference Proceedings (all cited in the chapter),
as this provides an excellent account,.of diverse international theory and practices and emerging
practices.

Online Resources

BACP website: www.bacp.co.uk.

BACP Children and Young People Division - see Competencies for Working with Children and
Young People.
Counselling MindEd: http://counsellingminded.com, especially CM 4.4: The Range ofCreative and
Symbolic Methods with CYP.
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 Part 2

Counselling Practices and

Processes
 Referrals and Indications for
Therapy
Ani de la Prida and Wendy Brown

This chapter includes:

e Background to child and adolescent mental health policy

e Legislation relevant to referral
e Referral forms and relevance to assessment
e Influence of counselling modality on referral process
e Indications for therapy
e Potential dilemmas and good practice

Introduction

This chapter is designed to inform referring agencies, practitioners and counselling

services. It raises points for discussion and highlights a number of aspects influenc-
ing referral. It explores the background to UK child and adolescent mental health
policy alongside influential legislation relevant to referral. We consider referral
forms and their relevance to assessment, highlighting the influence that the coun-
selling modality can have on the referral process. We discuss indications for therapy
and explore a variety of settings before highlighting potential dilemmas and good
practice.
130 The Handbook of Counselling Children & Young People

Referral is an important part of the counselling process, although one that in our
experience may be overlooked at times. When considering the counselling process as
a whole, it is perhaps difficult to determine the most significant aspect that enables
change to occur for each client. Of recognised importance to the counselling process
are the therapeutic conditions (Prever, 2010) and therapeutic alliance (Muran and
Barber, 2010), but the referral is where we really start the work with each client. It is
where we begin to develop a relationship, where we gain a ‘picture’ of the client in con-
text and where we have an opportunity to create dialogue that can contribute towards
therapeutic change.

Policy Background and History to Referral System

Currently there is no single UK system or policy for referral, but a variety of ways in
which children and young people come to counselling, further complicated by the vari-
ation in legislation and policy within each of the of the four nations. Although not an
inclusive list of all legislative policy, the following key points have a focus on the health
and emotional well-being of the UK’s children and young people, influencing the com-
missioning of services.

Table 9.1 CAMHS’ four-tier system.

Tier 1 — provides treatment for less severe mental health conditions, such as mild depression, while
also offering an assessment service for children and young people who would benefit from referral to
more specialist services.
Services at this level are not just provided by mental health professionals, but also by GPs, health
visitors, school nurses, teachers, social workers, youth justice workers and voluntary agencies.

Tier 2 — provides assessment and interventions for children and young people with more severe or
complex health care needs, such as severe depression.
Services at this level are provided by community mental health nurses, psychologists and counsellors.

Tier 3 — provides services for children and young people with severe, complex and persistent mental
health conditions, such as obsessive compulsive disorder (OCD), bipolar disorder and schizophrenia.
Services at this level are provided by a team of different professionals working together (a multi-disciplinary
team), such as a psychiatrist, social worker, educational psychologist and occupational therapist.

Tier 4 — provides specialist services for children and young people with the most serious problems,
such as violent behaviour, a serious and life-threatening eating disorder, or a history of physical and/
or sexual abuse. Tier 4 services are usually provided in specialist units, which can either be day
units (where a patient can visit during the day), or in-patient units (where a patient will need to stay).
Depending on the nature of the condition, this could be a stay of several days to several months.
 Referrals and Indications for Therapy 131

Child and Adolescent Mental Health Services’ (CAMHS) provision in the UK is organ-
ised around a four-tier system of assessment and delivery of services first outlined in an
NHS Health Advisory Service review (1995). However, not all CAMHS offer counselling
services; Richardson et al. (2010) point out that differing interpretations of the tiers have
resulted in the very confusion that the system was designed to resolve. Referrals may
be assessed in terms of the four tiers (see Table 9.1), although outside of the NHS many
organisations do not make reference to it at all.
The need for clear referral and acceptance systems is recognised by practitioners,
with specialist CAMHS and counselling services largely agreeing on criteria for appro-
priate referral (Spong et al., 2013). However, a clear route for communication, referral
and consultation between counselling services and specialist CAMHS is not always
available or seen as appropriate or supportive (ibid.). Spong et al. (2013) also highlight
that at times there are difficulties between counselling services and specialist CAMHS
where counsellors are critical of the rationale of specialist CAMHS, which is likely to
have an impact on referrals from counselling services.
The Youth Justice Board Mental Health Report (Harrington and Bailey, 2005) points
out that the CAMHS framework necessitates a holistic assessment approach, and that
local and regional partnerships are necessary for consistent provision of services.
Provision and assessment, however, are inconsistent (Mulley, 2009), and dependent
on partnerships with public, private and voluntary organisations which are at times
disjointed (DoH, 2005; Spong et al., 2013).
Recent research highlights that children and young people are more likely to be
referred to a professional for behaviour than for emotional difficulties, with mental
health support being provided principally by teachers (DfE, 2011). More worryingly,
the DfE report states that in their study ‘no primary or secondary schools reported
using approaches that involved following a rigorous protocol’ (2011: 10). This picture
suggests children and young people may not always be referred when appropriate or
needed.
A BACP scoping report points to recent figures which suggest that the numbers attend-
ing school-based counselling are similar to the numbers attending specialist CAMHS
services (Cooper, 2013). The report suggests that counselling is currently available in
approximately 60 to 85 per cent of secondary schools in the UK, whilst there is mixed
provision in primary schools (Spong et al., 2013). Cooper (2013) highlights that sources
of referral to school counselling services include parents, school staff, and self-referral,
although the most common source of referral is school staff. In particular, pastoral care
teachers were reported to be involved in approximately two-thirds of referrals.
Counselling services in the community and voluntary sector are an important part
of mental health provision for children and young people. A recent report estimates
that there are approximately 100,000 referrals per year for children, young people and
young adults (Street, 2013).
132 The Handbook of Counselling Children & Young People

Referral Forms and Assessment

It is difficult to separate referral and assessment as the two are linked and often inter-
twined. Different theoretical orientations have different ways of assessing (or not
assessing) clients, which will discernibly influence the information sought as well as
the referral process. The structure of the setting will also shape the referral process both
in terms of information requested and also who is seen or referred on. Therefore there
is a huge diversity in terms of referral and assessment practices in the UK, and localised
referral policies and forms will naturally reflect this.
Some settings prefer a written referral to be completed before seeing a client, for
example specialist CAMHS require written referrals from a GP, social worker or other
professional. Drop-in centres, schools-based counselling services and community-
based services may not require referral or assessment documentation, whilst other
counselling services may ask clients to meet with a counsellor to complete a referral or
assessment form during an initial session.

Reflective Question
Imagine you are a counsellor working in a school-based service. You receive a referral
form. What information would you want the form to contain that would enable you to
make an informed choice about accepting the client or referring on?

Discussion

Ideally, information on a referral form would include the client's voice, whether the
client wants to come to counselling, the nature of the problem, how long the diffi-
culty has been experienced, and any information considered relevant to the issue.
For example, in the case of bereavement the form should include details of the loss.
Information about the context of the client may be useful, for example if the child has
just moved to the school or local area.
The form should also contain information about any serious issues, such as child
protection. Decisions to accept referrals would be informed by modality, limits of
competency and counselling service policy.

Referral forms could be considered inherently flawed in that they are predominantly
created for the needs of the setting rather than the client, they often contain other people's
perceptions — and the younger the child the less likely that they will contain the client’s
words or view.
 Referrals and Indications for Therapy 133

Although a referral form can contain much information about a client, it is impor-
tant to remember that it may not be the client’s opinion. It may contain biased opinion,
for example one teacher may see behaviour as unmanageable that others, and the client,
would view as acceptable. Referral information may not be accurate, for example infor-
mal assessments and diagnoses such as ‘Jane has low self-esteem’ may be inaccurate.
It is important to be able to hold the information on a referral form in mind without
allowing it to prejudice your view or opinion of the client before you have even met.
Relevant information may also be missing at referral, for example a recent bereave-
ment may not be mentioned unless the referrer is prompted. Perceptions of those
referring may be distorted by their own difficulties, for example a mother who is unable
to process her own grief at the loss of a partner may consider their child’s grief problem-
atic or abnormal — whereas the child’s expressed grief may be the healthier response.
The requirements and structure of settings will often create dilemmas, challeng-
ing ethical boundaries, theoretical stance and counsellor competence - for example a
counselling service policy to decline referrals for pre-trial therapy for children involved
in court proceedings because of the risk and complexity of managing the counselling
without prejudicing the client’s evidence (for further discussion see Chapter 17: “Law
and Policy’). This may not be in the client’s interest, however, and could be seen as con-
trary to the ethical principles of autonomy and beneficence (BACP, 2013).
Theoretical stance can also give rise to dilemmas with referral. For example there is
anecdotal evidence that specialist CAMHS services, particularly when working from
systemic and integrative perspectives, will decline referrals for counselling for looked-
after children on the basis that they must be in a stable environment before engaging
in therapeutic work. Other service providers working from modalities such as person-
centred therapy do not see this as a barrier to therapeutic work. In fact it could be
argued that the child’s need is greater during periods of instability than when their
environment is stable. Declining requests for therapy on this basis could also be seen as
contrary to the ethical principles of autonomy and beneficence (BACP, 2013).

Good Practice

At referral it can be useful to include or have information on:

Client's voice
~ Current family status (both parents, lone parent, step-parent, carer, adopted)
@
ee Is the child subject to a child protection plan/order?
e
_ Is the child a looked-after child— if so, placement history?

(Continued)
 134 The Handbook of Counselling Children & Young People

(Continued)

Any current medications?

Behaviours or issues causing concern?
What is the hoped for outcome of therapy?
Any recent losses, bereavements, or major changes?

fe Study Josh
Referral from Greenwich Town High School to ABC Counselling Services
Josh, DOB 6.6.97. 15 years old — Year 10
Lives with mum and dad, no siblings. No medication.
Josh’s behaviour is causing concern. His previously good grades are rapidly in decline and he has
poor attendance. We are concerned he is truanting, although mum says Josh’s absences are due to
illness recently and she forgets to inform school. No GP evidence to support any illness.
Josh had been a pleasant but quiet student, but is increasingly defiant and disruptive in class. He
is tired and easily distracted, and has fallen asleep in class. He seems to be getting into fights, and
recently had a black eye which he said he got from ‘walking into a door’ There are allegations of bul-
lying by Connor, a Year 7 boy, although Josh denies this. Recently Josh was excluded for three days
for punching Connor in the face.
We are concerned that Josh may be using drugs or alcohol and that he may be stealing as a num-
ber of items have gone missing in PE.
Our initial suggestion for counselling was refused by Josh. We contacted Mum, and Josh has now
agreed to counselling
MS 4

Reflective Question

What are your initial thoughts on working with Josh? Which ethical principles would
you specifically consider with this case?

Discussion
It is important to notice that the referral information is based entirely on informa-
tion from those surrounding Josh. It is not clear if Josh wants to attend counselling.
 Referrals and Indications for Therapy 135

In terms of the BACP Ethical Principles (2013) this would highlight the need to pay
attention to autonomy to ensure that Josh's right to be self-governing is supported.

Below is an example of the notes that Josh’s counsellor made in response to the referral,
and the first two sessions with Josh.

Denise Josh’s Counsellor )

Case Notes

Initial Reflections
Josh's voice is entirely absent from the referral form — has anyone asked Josh how he is feeling? Can
he open up? He sounds angry - why?
His behaviour could suggest drug use — is he stealing? | can feel my assumptions forming of a rude,
aggressive teenager — he reminds me of my nephew. Can | put these feelings aside and open myself
up to see the real Josh?
Josh refused counselling initially - did mum insist he attend? If he has been coerced is it ethical
to start sessions? No mention of dad - why? How can | enable Josh’s voice and support his choice to
not attend if he wishes?
| need to pay attention to Josh's autonomy at the start.

Supervision Notes
Session1
Josh was very angry and reticent at our first session, ‘Everyone has it in for me’ he said. | explained
he could choose to not come, and that | would support his choice - hopefully this will help him build
some trust with me. He was concerned about confidentiality - | wonder why? | agreed to discuss
with him first anything | might need to disclose. He was very angry about Connor and said they had
a fight.
Session 2
Josh opened up and told me that dad is alcoholic. There is violence at home, Josh is angry and pro-
tective of mum — does he get hurt trying to protect mum? His absences from school are when mum
is ‘ill’—she refuses outside help. He is often awake at night because he is worried. Connor, who gave
Josh a black eye, is bullying Josh. Josh has asked me not to tell anyone, says he'll deny it. He feels
stupid because Connor is younger. | am concerned - if | break confidentiality now | think Josh will
disengage, leaving him more vulnerable. | need to explore further in supervision. )
136 The Handbook of Counselling Children & Young People

Reflective Question
How accurately did the referral capture Josh's situation?

Discussion

Referrals often may not accurately capture the client’s situation. Looking at Denise's initial
reflections and supervision notes, notice where you made assumptions or judgements.
How able would you have been to meet Josh without prejudice after reading the referral?
Past experiences, culture and even media images shape our perceptions of children and
young people (Prever, 2010), and recognising these is important in order to see the client
beyond the referral form.

Initial Referral Meeting

Initial referral meetings often include the child and parent. This meeting gives the
counsellor an opportunity to hear where the difficulties may lie, and how these are
being felt and displayed by the child or young person. This is also an opportunity to
ensure that both parties fully understand what counselling is, and just as importantly,
what it is not. With an older child or young person who doesn't have an adult present,
it is important to ensure that you check their understanding throughout the process.
With a younger child the initial consultation session can be a transitional space for
parents and child to traverse the space from parental authority to having individual
sessions. At times it can also be a difficult session for the child. He may not want the
adults to share information about him, or he may not agree with what is being said.
It is important to ensure that the child has a voice at these meetings. It can also be a
difficult session for the counsellor, who may experience the parent as judgemental or
punitive towards the child. This can be a tricky scenario to manage, particularly when
a counsellor is in private practice, as payment can create an additional dynamic with
a parent. Managing boundaries and expectations is important, and this initial referral
meeting can help build a therapeutic relationship and ensure clear understanding of
the boundaries of the counselling work.
There are particular issues around client agenda that are complex to balance at times
but which need careful attention at referral. The reason for referral may be a parent's,
but the parent's agenda may be different to the client's. For example, a young person
may be referred by a parent for being angry at home, but the young person may choose
to explore their sexuality rather than their anger, and they may only disclose this to
 Referrals and Indications for Therapy 137

the counsellor in private. Paying attention to this possibility is important to ensure an

autonomous space for the client.
Difficulties can also arise around expectations at referral. Clear information and con-
tracting at referral can support the work by informing realistic expectations and verbalising
therapeutic aims. For example a parent who brings a child who is ‘sad’ to counselling may
become disturbed if their child appears to become angry or unhappy through counsel-
ling. Changes that occur as part of the client's therapeutic growth process — for example,
because the child is revealing previously hidden feelings - can make it seem that counselling
isn't working or is even making things worse. Discussing this at referral can help support
the therapeutic work. It is important therefore to give clear information at the outset for
parents/referrers, explaining what may occur as part of the counselling process.

Different Modalities’ Perspectives

It can be difficult to separate referral and assessment as the two are intrinsically linked.
A referrer in a sense has already made an assessment that a child or young person
would benefit from counselling. The information required from a counselling service
or practitioner at referral will seek to explore this further and may even include an
assessment before a child or young person is accepted for counselling. It is important
to recognise that there are a wide variety of referral systems and practices, which are
also influenced by modality.

Systemic

Some therapies - particularly attachment focused, family therapy and systemic — are
likely to carry out more lengthy assessments as part of the referral or initial assess-
ment. Observational assessments often include all family members and a team of
professionals either in the child’s home or at the clinic, and may last for a whole day
or over a number of sessions. Referral information sought can include details such
as chronology, nurture-trauma timeline, health, diary of daily routine and behaviour,
formal reports from parents, professionals, school, examples of schoolwork, and details
of previous assessments. Examples of questionnaires that may be used at referral and
assessment include:

e the child behaviour checklist

e anexecutive functioning questionnaire
e achild trauma checklist
138 The Handbook of Counselling Children & Young People

e aparental stress checklist

e the ACC
e Connor's questionnaire

For further information see the Comprehensive Multi-disciplinary Child Assessment

(Family Futures, 2014).

Cognitive-Behavioural Therapy (CBT)

CBT therapists use structured assessments to develop individualised treatment plans

designed to help children restructure their thinking and learn new problem-solving
skills. Tests may be used at referral to measure symptoms, and a clear idea of issues
to be worked on will usually be agreed as part of the assessment. CBT with children
and young people may include books or manuals designed to teach the client about
the relationship between thoughts, feelings and behaviours (The Centre for Cognitive
Behavioural Counselling, 2014).

Psychodynamic

Psychodynamic practitioners consider that assessing at referral requires specialised

skills, and that the assessment process itself can be a helpful ‘exploration which leads to
a variety of treatment possibilities’ (Rustin and Quagliata, 2000: 1). The psychodynamic
model uses observation and pays attention to the transference and counter-transference
(i.e. feelings elicited in the therapist). The therapist may use questionnaires to gather
information, and may ask to observe the child with parents and interpret behaviours.
At referral the therapist will be seeking to understand the child’s current situation and
past experiences, particularly attachment experiences (ibid.).

Person-centred

For person-centred practitioners the focus is on the client as expert, or at least equal in
the referral process with the therapist. Assessment is seen primarily as an opportunity
to explore with the client the appropriateness of counselling and not as a tool to
diagnose or determine treatment options (Gillon, 2013). Based on Rogers’ six condi-
tions being necessary and sufficient (Rogers, 2003), person-centred practice considers
that the treatment is the same whatever the diagnosis, i.e. the six conditions, and therefore
information and assessment at referral hold much less importance.
 Referrals and Indications for Therapy 139

Person-centred counsellors will generally ask fewer questions, want less background
information, and will be aiming to understand the difficulty from the client’s point of
view. Therefore the person-centred therapist may hold information from other parties at
referral lightly. They will pay attention to their own reactions and feelings, as well as their
client's, to inform an assessment of risk. A common difficulty for many person-centred
therapists is how to balance organisational requirements at referral that require a more
objective assessment without abandoning their own therapeutic stance (Prever, 2010).

Client’s Environment

At referral it can be important to understand the circumstances and relationships sur-

rounding the child or young person. Dilemmas can arise when the client’s difficulties
are being created by parents, whether because of abuse or because of poor parenting. A
child may disclose abuse or neglect at referral. This can be difficult in any setting, but
particularly when challenging the parent could result in them ending counselling for
the client. Working with a child or young person’s issues when the parent is contribut-
ing to or compounding a child’s difficulties is difficult and demanding for a counsellor
to manage, therefore supervision is an essential support. Reflecting on the dynamics in

The Referrer -TheCustomer _ The Identi

to whom who is mgsti,.__ _ Clients
correspondence about concerned that th ic
case should be sent _ referral be

Figure 9.1 Puzzle grid.

 140 The Handbook of Counselling Children & Young People

the child or young person's world can help deepen your understanding. The puzzle grid
(Figure 9.1), adapted from a systemic model, can be a useful and easy-to-use reflection
tool for the counsellor (Carr, 2004).
The puzzle grid tool can be used as a guide to identify key people in the referral
process who can help the counsellor gain an overview of the structure surrounding the
child or young person. In using the tool it is important to ask the following questions:

e Who has decided the child needs therapy?

e Whois referring them?
e Why are they referring this child?
e Does the child know about the referral?
e What does the child feel about the referral?

The case study below illustrates how one counsellor used the puzzle grid tool to
enable a deeper understanding of the client’s context, and of the therapeutic process.

eC 7.
Case Study Phillipa
Phillipa was an extremely shy 12-year-old girl living alone with her mother after Dad left nine months
ago. Phillipa was refusing to go to school and was referred by her GP after seeing her at an appoint-
ment with her mother, who was described in the referral letter as ‘beside herself with worry’ During
the first contracting session Phillipa seemed anxious and tearful a lot of the time. Using the puzzle
grid, Phillipa is The Identified Client and Mum is in the role of Customer and Legally Responsible
Person. Counselling began and a teacher was identified as Primary Supportive Figure. The counsellor
recognised two of Phillipa’s friends as Change Promoters. Sessions progressed and the work flour-
ished with Phillipa improving and returning to school on a phased basis. At this point, Mum contacted
the counsellor, worried that Phillipa was being bullied at school, and concerned about her getting
the bus to school in the mornings. There had been a minor incident, but exploring with Phillipa it
become clear that Mum's distress was the cause of Phillipa’s difficulty in leaving in the mornings.
Using the grid, Mum was identified as in the role of Change Preventer - Mum’s anxiety following Dad
leaving was possibly being unconsciously projected onto Phillipa. The counsellor showed empathy
and compassion towards mum and suggested she engage in her own counselling. She went ahead
with this and became able to separate her anxieties from Phillipa, and moved from being a Change
Preventer to a Change Promoter for Phillipa.
Xe ru
Indications for Therapy and Presenting Problems

Below are some examples of indications that children and young people may benefit
from counselling. The list is not exhaustive, and although most children do the things
 Referrals and Indications for Therapy 141

on this list at some time or other, it is the degree, persistence and proportion of symp-
toms that should guide a referral. Age is an important factor to consider, for example
mood swings and difficult behaviour are developmentally appropriate in a teenager but
less so in a six-year-old.

Persistent feelings of sadness or hopelessness

Children may not be able to talk about being sad, or even identify how they are feel-
ing as sadness, but may express this through their actions. This can include rudeness,
difficult or defiant behaviour, breaking rules, withdrawing or isolating themselves,
not being able to stop crying, refusing food, needing constant reassurance or clingy
behaviour.

Persistent or unexplained anger

Children and young people may express anger verbally in temper tantrums,
persistent refusal to cooperate, aggression or arguing. Anger may lead to aggres-
sive behaviour such as hitting, biting, shouting, breaking or destroying things or
self-harm.

Persistent anxiety or worrying

Children may become anxious because of parenting experiences or a recent event, for
example illness or death, separation, divorce, or a major change or move. Presenting
issues connected to underlying anxiety can include a preoccupation with physical ill-
ness or appearance, performing routines obsessively, or changes in patterns of sleeping
or eating.

Loss

Children may struggle with processing loss following events such as death, their par-
ents’ divorce, or a move, and may need to have some time to work through this in
counselling. They may present as constantly wanting to talk about the past, or seem
unable to separate past and present. They may also present as tearful, disengaged, with
poor concentration and memory, anxiety and difficulty sleeping.
142 The Handbook of Counselling Children & Young People

Withdrawal or isolation

A child may become reclusive, preferring to be alone all the time and isolating them-
selves from peers and family. Presenting issues can also include anxiety, depression, not
laughing or joking, not enjoying activities they once enjoyed, or a sudden, unexplained
drop in grades at school.

Other indicators include:

e Expressing thoughts of suicide

e Seeming very low or depressed
e Family difficulties
e Behaviour difficulties
e Repetitive or obsessive thoughts or behaviour
e Eating problems
e Bullying or being bullied
e Difficulties with peers and friendships
e Self-harm
e Alcohol or drug use
e Dieting obsessively, or bingeing followed by vomiting or taking laxatives
e An inability to concentrate, think clearly, or make decisions
e Returning to younger behaviours
e Seeking or asking for counselling
e Experiencing regular nightmares

Presenting issues

In terms of presenting issues recent research has identified that the most common
difficulty that young people seek referral to counselling for is family/relationship dif-
ficulties (Cooper, 2013; Street, 2013). In the voluntary and community sector, Street
(2013) described the most common reasons as:

e General mental health issues

e Challenging behaviour
e Self-harm
e Abuse/neglect
e Bullying
e Bereavement
e Suicidal feelings
 Referrals and Indications for Therapy 143

e Eating disorders
e Substance misuse

In addition to these, referral issues included depression, lack of self-esteem, rape, preg-
nancy, panic attacks, lack of self-confidence, paranoia and eating disorders. Of the
concerns or issues presented at referral some clients have multiple issues, and most of
those with multiple issues present with three to five issues.
Cooper's (2013) research in secondary school counselling found similar concerns or
issues at referral:

e Anger
e Behaviour
e Bereavement
e Bullying
e Self-worth
e Relationships in general

Anger was significantly more common for young male clients, with approximately 25
per cent reporting this as a difficulty at referral. He also noted that presenting issues
tended to change as therapy progressed, from anger towards relationships and self-
worth difficulties. In addition to these presenting issues, secondary school counsellors’
records also included depression, self-harm, abuse, and eating disorders.
A similar pattern of referral issues was reported in a report on primary school counsel-
ling, with Thompson (2013) citing Webb et al’s list of most common referral reasons as:

e Family problems
e Trauma and abuse
e Friendship and bullying
e Bereavement
e Anxiety

This report highlighted a worrying issue of inappropriate referrals, where referrals for
counselling have been made for classroom behaviour management difficulties rather
than the child being in need of counselling.

Specialist CAMHS

Referral to specialist CAMHS services can be dependent on local provision, relation-

ship between CAMHS and counselling service, counselling service policy and counsellor
competence. The four-tier system can be used as a guide to enable appropriate referral.
144 The Handbook of Counselling Children & Young People

Cooper’s (2013) research found that ‘92% of counsellors feel clear about when to refer a
young person on to specialist CAMHS or other services’ (2013: 5). Spong et al‘s report
includes a table (2013: 10), reproduced here as Table 9.2, showing accepted referral crite-
ria to specialist CAMHS as identified by CAMHS staff. School counsellors, however, see
clients with a wide range of difficulties, and there are no set criteria for who is considered
an appropriate referral for schools (Cooper, 2013). The list below is not conclusive and
is open to interpretation and further discussion. However, it usefully illustrates a broad
view of when a CAMHS referral may be appropriate.

Table 9.2 >Whena CAMHS referral might be appropriate.

School- or community-based counselling should

Specialist CAMHS should take referrals take referrals

Moderate to severe mental health problems Mild to moderate mental health problems
A clinical diagnosis Emotional health and well-being problems
Where risk needs to be ‘held’ Those who are not at risk

When multi-disciplinary skills are needed Those whose lives are too chaotic to attend regular
clinic appointments
Where social care elements are needed When services only available in community agencies
are needed (for example, drop-in)

In secondary school-age clients, Cooper (2013) found that specialist CAMHS in 2008-9
recorded the most common referral issues as:

e Emotional problems
e Self-harm
e Eating disorders
e Conduct difficulties
e Hyperkinetic problems
e Autistic spectrum problems
e Developmental difficulties
e Psychotic problems

Counselling Settings

Counsellors work in a variety of settings, and the setting in which the client is seen
will impact on the referral and on the therapeutic work. Whether in private prac-
tice or within service providers such as voluntary or statutory agencies and schools,
 Referrals and Indications for Therapy 145

surprisingly children’s rights - and consequently their rights within a therapeutic

relationship - vary. The diagnostic labels used to describe children’s behaviour and
distress can vary between agencies (Malek, 1991, 1993), and it is not unusual, there-
fore, for counsellors and therapists to become confused as to the limits of their work
with the child. Knowing when to refer on to specialist CAMHS, or when specialist
CAMHS should refer on to counselling, is therefore not always clear.

Schools

Counsellors in schools can find that some children perceive counselling as stigmatising
or as part of the disciplinary system, although the opposite can also be true with children
finding school counselling less stigmatising (Cooper, 2013). Work may be needed to
overcome a negative perception at referral, particularly drawing attention to the child
or young person's autonomy to choose whether they wish to engage with counselling.
Provision of school counsellors is increasing (Cooper, 2004, 2006; McGinnis, 2006),
and drop-in sessions within schools are becoming more common. There is, according
to independent legal opinion, no specific requirement in law for parents’ prior permis-
sion to be obtained before a child makes confidential disclosures to a teacher (Beloff
and Mountfield, 1994), but Gillick competency should be determined (Children’s Legal
Centre, 1997) when working with children in the UK.

Statutory Agency

A significant level of therapeutic work is provided by statutory agencies, such as

Children’s Services departments, specialist CAMHS, the NHS, and youth services of
local authorities. Provision is variable, although a more comprehensive and integrated
provision is being developed in response to guidance and directives (Spong et al., 2013).
Assessment-focused, time-limited, and risk-averse policies are likely issues for counsel-
lors in practice in statutory agencies, all of which can influence the referral process.

Voluntary and Community Sector

Given current constraints affecting statutory bodies, some of the greatest opportunities
for child-centred therapeutic practice are in the voluntary and community sector (Daniels
and Jenkins, 2010). Clients highlighted strength of this provision as the non-stigmatising
146 The Handbook of Counselling Children & Young People

settings, holistic approach and initial contact at referral (Street, 2013). However, agencies
may have limited administrative ability to gather data on outcomes or referrals, and agen-
cies may be reluctant to engage with routine monitoring (Street, 2013). Agencies will have
their own specific referral policies in place and practitioners need clear understanding of
these to ensure they work with cases appropriate to the agency’s work. For example, some
agencies work only with sexual abuse, whilst others may decline referrals from young
people who are using drugs. Each individual agency will also have policies relating to
confidentiality and child protection, for example information about self-harm may be
sought at referral with one agency whilst another may not require this.

Private Practice

There are many counsellors and therapists working with children and young people
within their own private practice. Rather confusingly, these practitioners are not neces-
sarily bound by the same requirements, such as referral policies or specific requirements
related to their therapeutic work, as those working in statutory or voluntary agen-
cies. For example, in terms of child protection, there is no legal requirement to report
suspected child abuse to the authorities, although the therapist would be justified in
doing so in the ‘public interest’ (Daniels and Jenkins, 2010). The increased freedoms in
private practice run parallel to an increase in responsibility and complexity the practi-
tioner carries. The self-referral process can leave practitioners vulnerable. For example,
risk assessment may be more difficult when working in isolation. Additionally, work-
ing in your own home carries vulnerability for the counsellor that can affect the referral
process. For example, a counsellor working alone at home may choose not to see clients
with a history of violence, and therefore this may form part of the information sought
at initial referral. Boundaries and risk need to be clearly and ethically explored by the
practitioner.

Good Practice Issues

Referring on to Other Agencies

Know your limitations and other clinicians’ strengths. (Lazarus, 2002)

There are various reasons for referring a child or young person onto another agency
and at the core of this action is recognition that this is in the child’s best interests.
Onward referral should never be viewed as a sign of a practitioner’s weakness, or lack of
 Referrals and Indications for Therapy 147

skill, but in fact quite the opposite. There are a number of possible reasons for referring
a child or young person onto another agency. These may include:

e The child’s presenting problems are outside the remit of the agency or counsellor
e The counsellor knows the child or the family on a personal basis
e tis appropriate for the child to access additional sources of support
e The child requires more specialist intervention, or a clinical assessment for a mental
health difficulty

It is important when referring on to check that the parent and the client clearly under-
stand the reason and do not interpret the referral as being because they are ‘too difficult’
‘too complex’ or ‘too ill.

Abuse and Investigations

There are difficulties with a referral for children and young people when there are
issues of abuse under investigation. There are risks and fears associated in seeing cli-
ents in this situation - for example, that a counsellor may potentially damage the case
by influencing a client’s testimony (see Chapter 17 for further discussion). This situa-
tion in itself is not a reason to decline a referral, although many agencies may wrongly
believe this to be the case.
There may be fear around the possibility of notes being requested, or of a counsellor
being required to give evidence. A disproportionate fear of the risk means that services
may decline referrals until after the court case rather than risk damaging the prosecution,
or opening a counsellor to scrutiny. However, a client may be in great need of support
at this time, and The Cleveland Report states: ‘there is a danger that in looking to the
welfare of children believed to be victims of sexual abuse the children themselves may be
overlooked. The child is a person and not an object of concern’ (Butler-Sloss, 1988: 245).
Children have a right to influence decisions made about them (HMSO, 1989, The
Children Act), and before declining a referral the potential impact on a client in this
circumstance must also be considered in terms of the ethical framework (BACP, 2013).
Careful assessment, understanding of legal issues and clear and open communica-
tion with referrers can help ensure good practice.

Looked-After Children

There are particular issues and contexts surrounding referrals for looked-after chil-
dren. In 2011 there were over 83,000 children in the UK care system (Royal College of
 148 The Handbook of Counselling Children & Young People

Paediatrics and Child Health, 2012). Looked-after children’s mental health difficulties
are exacerbated by their experiences, for example loss, poor parenting, abuse, poverty,
neglect, insecurity or a combination of these issues. There is a statutory duty to ensure
that looked-after children’s health needs are assessed at regular reviews and that they
have access to a range of services (ibid.).
However, referrals to counselling often take longer to be made because a number
of professionals, e.g. child’s social worker, team manager, foster carer, supervising
social worker, school, child’s guardian, as well as the parents, will need to be consulted.
Referring information may be substantial, complex and at times inconsistent, partly
due at times to the fragmented history of care around the child or young person. For
example, a complete history of the child’s behaviour might be provided whilst details of
a close family bereavement might be missing. The issue of different agendas at referral
is compounded here with the potential for a variety of agendas to be at play. At referral
it is important that the therapist takes extra care to ensure that the voice of the child is
heard amongst the competing agendas and substantial referral information.
Looked-after children are often in unstable settings, for example having multiple
placements. Referrals to specialist CAMHS may be declined ifa child or young person
is in an unstable setting. The reason for this is primarily one of modality. Although a
stable environment may be desirable, this in itself is not a reason to decline a referral
for therapy for many modalities, for example person-centred. The interest of the client
should be paramount and the potential impact of declining a referral should be consid-
ered in terms of the Ethical Framework (BACP, 2013). If a referral is declined on this
basis, then a client in need of therapy should be referred on to a service that is able to
provide counselling. Sadly, many children in care experience years of instability, and
the risk in declining a referral in this situation is that it may take years before a child
receives the support they need.

Case Study Amanda )

Amanda, aged 11, is the elder sister of two brothers, aged three and five. All siblings were taken into
care 18 months ago, due to severe neglect, parental drug and alcohol use and failure to keep the
children safe. When living at home Amanda looked after Mum and did most of the cooking and car-
ing for her brothers. The siblings were separated when Amanda’s brothers were placed with a foster
family 15 miles away.
Amanda lived with foster carers for seven months, but they struggled as she refused to attend
school, became violent and kept running away to try to return home. A referral to specialist CAMHS
was sought, but following assessment the referral was declined, advising that Amanda needed to be
in a more stable placement before therapeutic work was undertaken. There was no onward referral
ied,
 Referrals and Indications for Therapy 149

‘pee by the CAMHS team at this time. The carers were unable to contain Amanda’s violent outbursts
and the placement broke down.
Amanda moved to foster carers 40 miles from her family. Amanda settled somewhat, but after
four months the carers reported that Amanda was becoming withdrawn and aggressive, and had
difficulty making friends following a change of school. A referral was made to the specialist CAMHS
team in her new area, which had a waiting list of 12 months. A referral was also generated to a
national children’s charity counselling service that was able to offer an initial appointment within
four weeks. The counsellor met with the social worker and foster carer to begin with, to enable
clear contracting and obtain consent from the social worker to start counselling. This gave every-
one an opportunity to speak about their current concerns and reflect upon the behaviours that
Amanda was currently displaying and what they might be indicating. The social worker decided
that due to Amanda’s recent chronology it would not be in her best interest to be at the refer-
ral meeting as she wanted to give the counsellor a full history. The foster carer also completed a
Strengths and Difficulties Questionnaire, which the counsellor scored. Once the parameters of the
counselling had been contracted it was arranged that Amanda be invited in with her foster carer
to meet the counsellor.
Amanda’s first session included the foster carer. The counsellor advised Amanda that she
had already met the carer and her social worker, and listed some of the concerns they had. She
expressed that these opinions may or may not be ‘correct’ in Amanda’s eyes and her role was to
understand how things were for Amanda, and to offer her a space each week. Amanda avoided eye
contact and shrugged her shoulders. During contracting the counsellor acknowledged Amanda's
disengagement, and offered Amanda six sessions, with a planned break at session five in order for
Amanda to identify for herself whether she wished to continue. The counsellor felt that Amanda's
overall presentation showed signs of avoidant attachment rather than being resistant towards
counselling.
The counsellor used YP-CORE in each session, mapping scores onto a graph each week to show
any change. The building oftrust was slow, and the main focus for Amanda each week was anxi-
ety about how her mum and brothers were coping without her to ‘look out for them. Amanda
was unhappy at having monthly contact with her mother and siblings and she worried con-
stantly about them. The counsellor took account of the Getting It Right For Every Child (Scottish
Government, 2008) principles and, with Amanda's knowledge and consent, sent a letter to her
Local Authority social worker, stating that such lengthy periods between seeing her siblings and
mother were impacting on her emotional well-being. She requested that this be considered at
Amanda's next review meeting. The counsellor noticed that from session four onwards Amanda
was disengaging, and she felt this was likely to be due to the sessions drawing to an ending. She
knew that it was common for some children to ‘shut off’ when there was a change approach-
ing. The counsellor worked hard to ensure Amanda understood she had the choice to return to
sessions after the sixth session, as they had agreed when contracting. After the break Amanda
chose to continue with counselling. The counsellor noticed that Amanda seemed more willing
to engage.
Nee
 150 The Handbook of Counselling Children & Young People

Summary

To sum up, it is important for referrers to aim to provide clear, unbiased and accurate referrals.
The referral system surrounding the child or young person can be complex at times. Policies,
organisational settings, and theoretical stance can influence the process in ways that may not be
in the client’s interest. Information received at referral may be incomplete, inaccurate or biased. For
the practitioner, remaining able to meet the child without a prejudiced view caused by infor-
mation at referral isn’t easy and can be challenging. Experience, supervision and reflection can
help to develop the counsellor’s capacity to manage the challenges of referral when counselling
children and young people.

Key Points

e There is no single referral system in the UK

e Child and Adolescent Mental Health Services’ (CAMHS) provision in the UK is organised around
a four-tier system of assessment and delivery of services which influence referral
e Referral is influenced by counselling setting, service provider policy, modality and client's
context
e It is important to recognise that the information received at referral may be inaccurate or
incomplete and the child or young person's views may not be present
e Referrals to specialist CAMHS that are declined for looked-after children due to placement
instability should be referred on to an alternative counselling service

See ea mete eh meme rare eee fee eS Nf, Fy | | ot oe

.
I Learning Activities i
a i
hep Using one of your clients, apply the puzzle grid to identify the various roles surrounding l
; the child in order to gain a deeper understanding of the client’s situation. Then discuss :
with a peer, tutor or supervisor.
\ 2. Design your own referral form, and then discuss with a peer, tutor or supervisor. '
, > Work through the Counselling MindEd module CM 2.6 on risk assessment, available at ;
i www.counsellingminded.com. I
s = eee
 Referrals and Indications for Therapy 151

Further Reading

Richardson, J. (2002) The Mental Health of Looked-After Children. Bright Futures: Working with
Vulnerable Young People. London: Mental Health Foundation.
Spong, S. Waters, R., Dowd, C. and Jackson, C. (2013) The Relationship between Specialist
Child and Adolescent Mental Health Services (CAMHS) and Community-Based Counselling
for Children and Young People. Lutterworth: BACP/Counselling MindEd. Available at: www.
counsellingminded.com.

Online Resources

Counselling MindEd: http://counsellingminded.com, especially CM 2.1: What Is Assessment in

CYP Counselling?; CM 2.2: Engaging the CYP in Collaborative Assessment; CM 2.3: Areas to
Consider Assessing with the CYP.
 Preparation for Therapy:
Beginnings
Dave Stewart and Edith Bell

This chapter includes:

The primary importance of listening to children and young people in the preparation for ther-
apy process
The need to tune-in to different ages, developmental presentations and preferences to help chil-
dren and young people access and articulate their thoughts and feelings in the preparation phase
The importance of amore’active counsellor’ stance in assisting young clients to feel more con-
fident in expressing emotion and more at ease in the therapeutic relationship
‘Collaborative assessment’ as a new development within the CYP counselling field
Seven collaborative assessment tasks that together create a‘preparation for therapy map’
Some of the key constructs from within child development theory that underpin safe and
effective preparation for therapy: Piaget's (1936) theory of cognitive development (including
‘schema’ formation), Bronfenbrenner’s (1979) ‘ecological systems theory’, Gardener’s (1983)
‘multiple intelligences’
and Vygotsky’s (1934) ideas about the ‘zone of proximal development’.

Introduction

Listening to Children and Young People — the Critical Preparation Task

In his book Equals, child psychotherapist Adam Phillips (2003) provocatively invites
us to reconsider therapy as a ‘listening’ — rather than ‘talking’ - ‘cure. Few of us would
 Preparations for Therapy: Beginnings 153

argue about the prime importance of listening in our work. Why then can it be so
difficult to really listen to children? Why do we sometimes find it hard to let go of
‘counsellor-knows-best’ when deciding how to shape work with young people? What
barriers do therapists face in trying to centralise the voice of a child/young person in
therapy? In hearing the views of key adults in a child’s world - often an important part
of the initial listening process and especially with younger children — how do therapists
hold and contextualise the potential ‘clash’ of voices? What templates and structures
might helpfully scaffold the preparation listening process to enable a young client to
define what they want from counselling? And - what theories should counsellors be
aware of when preparing a CYP for therapy?

Preparation for Therapy — Unexplored Territory within CYP

Counselling

A search of BACP journals over the last five years confirmed that this has not been a
priority area to date. While Therapy Today, Counselling and Psychotherapy Research and
Counselling Children and Young People host a good number of articles on research, theory
and practice with CYP, there are only two pieces specific to the preparation therapy
phase. First is an interview with Ruth Schmidt Neven (2010) exploring her book Core
Principles of Assessment and Therapeutic Communication with Children, Parents and
Families; however, it comes from a sister therapeutic tradition - psychoanalytic child
psychotherapy - as opposed to CYP counselling. The second is a short article by Liana
Lowenstein (2011) looking at creative assessment techniques, in-tune with counselling
within an integrative orientation.
Overall, however, it would appear that preparation and assessment with CYP from
a humanistic orientation is a neglected area within the literature. Perhaps counsel-
ling preparation and assessment are unexplored territories because they are seen as
places outside the core humanistic counselling map. With historical roots within the
‘anti-medical model’ movement, assessment can be seen as antithetical to what coun-
selling stands for. Its seeming need to label, prescribe and diagnose places it beyond
counselling’s horizon. Indeed some counsellors might agree with Worrall (2006) that
the only task during preparation/contracting is ‘to create with them [the client] a
relational climate that will most effectively facilitate their self-directed exploration
and development (p. 52). For others there is a conviction that it is even contrary to
Rogers’ ‘core conditions’:

within the person-centred domain the question of assessment is ridiculous: the asses-
sor would have to make a judgement not only about the client but on the relational
dimensions between the client and the counsellor. (Mearns, 1997: 91)
154 The Handbook of Counselling Children & Young People

Contemporary Developments and Their Impact on Preparation

Practice in CYP Counselling

However, the ever-growing field of CYP counselling is pushing at historical bound-

aries of what is necessary and feasible within the counselling map. As it does so it
is articulating more clearly what it does and how its work, of necessity, differs from
adult counselling. For instance, BACP’s ‘CYP Competency Framework for Humanistic
Counselling’ (2014) - a landmark document in our development as a profession — has
‘ability to conduct a collaborative assessment’ as one of its generic therapeutic compe-
tencies. To create safe and effective practice counsellors must scaffold the preparation
process in developmentally-attuned ways that both facilitate each CYP to draw a map
of their territory and enable the counsellor to fine-tune the picture to illuminate any
areas of risk or vulnerability.
Inevitability this means donning a more active role in the preparation phase.
Katy McArthur’s (2013) qualitative research of secondary school counselling
highlights that ‘emotional expression’ is seen by young people as the most helpful
aspect of their therapy, with difficulties in talking about emotions the key hinder-
ing factor.
Young people in the study also preferred a more ‘active counsellor’ approach: asking
questions, offering advice, providing psycho-education and self-help strategies. These
counsellor-led activities are seen to reduce anxiety, overcome barriers to emotional
expression and create a sense of ease in the relationship.
Similarly, research carried out by Barnardo's (Regan and Craig, 2011) with primary
school children indicated that ‘talking about feelings’ and ‘counselling activities’ were
the two aspects children mentioned the most in interviews.
Activities - carefully attuned to the client's developmental presentation and preferences —
help mediate the content of these critical preparation phase conversations. The right
activity helps a child get beyond some of the barriers to accessing and expressing
emotion. Perhaps what looks like non-engagement is really crying out for a less verbal,
more ‘right-brain’ approach. Here we might find that introducing something visual,
like a series of ‘feelings faces’ to map responses to key areas in a client’s life, can break
the silence. Or maybe an invitation to use the sand-tray to ‘tell a story of me and my
world’ will unlock the communication pathway.
For others, the winning activity is more ‘left-brain’ and verbal, with structured
questions establishing grounds for conversation: ‘In your family ... who is the safest
person to talk to when you've had a hard day? Who is the best at being angry? Who is
the one who sorts out fights between you and your brothers?’ Scaling might also help
a child with a more cognitive preference: ‘On a scale of 1-10, where 1 is the worst and
 Preparations for Therapy: Beginnings 155

10 is the best, how would you score your relationship with your teacher ... the two
friends you mentioned ... your new step-dad?’ A client’s self-perception in relation to the
reason(s) they are seeking support is another area often requiring a lateral approach
from counsellors. Here asking a child/young person how their ‘best friend ... mum ...
favourite teacher’ might describe them, their strengths and qualities, can help access
a useful self-perspective.
By adopting this flexible, adaptable approach counsellors can scaffold their
input, moving ‘up and down’ a framework of activities until they find the right
‘fit’ for each client’s developmental presentation and preferences. This ‘back-and-
forth movement calls for a capacity to ‘learn from our mistakes and mis-attunements’
in a creative listening process that ultimately helps access the CYP’s voice and
story.
Our experience is that none of this need be at odds with counselling’s com-
mitment to the therapeutic alliance, client autonomy and self-determination.
Assessment can be a highly collaborative activity, a rich opportunity to get to
know a CYP, establish a strong partnership and through this catch a view of their
map of the territory. It is about generating ‘constructive understanding’ (Sharry,
2004) to inform preparation for therapy and its development at each successive
phase. We will now go on to look at preparation process and practice in more
detail.

Making the ‘Preparation-for-Therapy Map’: Seven Key Tasks

We have identified seven key tasks in making the ‘preparation-for-therapy map’ (see
Figure 10.1).

Pre-preparation — therapist and environment

Facilitating the C/YP to create a personal preparation-for-therapy map
Mapping risk
Mapping the context
Integrating the standardised measures map
Reviewing the ‘assessment meta-map’
=NOTAROD
Contracting

Figure 10.1 Seven key tasks of the preparation-for-therapy map.

156 The Handbook of Counselling Children & Young People

First Preparation Task: Pre-preparation — Therapist and

Environment

The preparation process begins before client and counsellor meet. In her article “Therapist
as Host: Making My Guests Feel Welcome’ (2006), Jodi Aman notes the importance of
attending to the physical environment within which we meet clients, hypothesising that
‘a calm space supports a person in getting distance from the immediacy of their experi-
ence, therefore enhancing the effectiveness of the conversations’ (p. 8).
Leaflets, voicemail messages and websites need to sound a warm, welcoming
approach, and Aman gives examples of children’s art work and a child-friendly intro-
ductory letter from her website. Her ‘therapist as host’ metaphor is useful for shaping
therapists’ own preparation before work with a new client:

treating someone as a cherished guest addresses the power differential undisputable

in a therapeutic relationship by elevating the status of the person who comes to con-
sult the therapist. (p. 4)

Addressing the power differential is of particular importance in CYP counselling,

where elevating the status of the CYP serves as an essential guard against a ‘therapist-
knows-best’ attitude, itself a subtle but insidious barrier to listening.

Second Preparation Task: Facilitating the CYP to Create a Personal

Preparation-for-Therapy Map

The territory to cover here involves accessing CYP’s views on why they are com-
ing to therapy and the impact the perceived problems, issues and situations are
having on each aspect oflife - personal, family, school, friendships/relationships,
hobbies, values/beliefs. Crucially, we also ask the CYP to map the strengths and
resources they identify in themselves, family, peer group, school, and wider com-
munity. Identifying strengths provides a bridge from problem perception to goal
setting.
The map should also include specific goals - usually no more than three - creating
a transparent baseline for what change will ‘look like. Goals are best expressed as the
presence of something new or different in the child’s life as opposed to the absence of
something difficult (e.g. ‘I want to start doing X’ rather than ‘stop doing Y’).
There are a range of approaches and techniques here, from the strengths-based
information gathering outlined by Sharry (2004) to the creative techniques indicated
by Liana Lowenstein (1999, 2011), to structured therapeutic games such as All About
 Preparations for Therapy: Beginnings 157

Me (Hemming/Barnardos). Age, developmental level and temperament/specific inter-

ests will dictate the right blend of methods for each child/young person.

Third Preparation Task: Mapping Risk

Issues of safety are central within CYP counselling. Historical, existing or potential risk
therefore needs to be part of the mapping process. When working with children under
12, this includes engaging with parents/carers in risk identification and assessment.
Areas for inclusion on the risk map include:

¢ parent/carer or young person with mental illness, current or historical;

e child/young person on the ‘at risk’ register;
e young person indicating wish or intent to harm self or others;
e history of abuse, neglect, domestic violence, other trauma;
e misuse of alcohol and/or other drugs;
¢ parent/family member in prison;
e newcomer/immigrant black/ethnic minority family
e multiple bereavement; ;
¢ poor school attendance;
e poor parental involvement (for children 6-12);
e impact of learning or other disabilities;
¢ emotional communication difficulties;
e significant life-cycle transition in combination with any of the above.

Risk assessment informs whether counselling is a feasible support at a particular time

in a young client’s life. It contextualises other key preparation phase decisions too,
including the counselling goals agreed - what is realistically possible given the risks
identified? - the timeframe for reviews — should reviews occur more often in the light of
assessed risk? - and any safety planning required for safe, effective counselling to occur.
Risk assessment entails enquiring about other services involved with the family -
social services, CAMHS, etc. - and explicitly contracting to liaise with these services as
part of the overall assessment. With identification of risk comes an increased need to
triangulate services so that counselling is contextualised within a network of supports.

Fourth Preparation Task: Mapping the Context

To fully appreciate the unique circumstances shaping the CYP’s personal map we must
contextualise it within the larger territory of family, school and community maps. From
158 The Handbook of Counselling Children & Young People

a developmental perspective this is particularly important in work with under-12s and

with young people who present as 12 or under, due to learning or other disabilities.
Supporting adult carers during the preparation phase - including school staff where
the service is school-based — recognises the key role they play in defining and, some-
times, constraining the maps children live by (Perry and Szalavitz , 2010). An assessment
with parents/carers can happen with the adults only or with the child/young person
present for all or part of the meeting(s). Covering the same ground as outlined in the
child/young person assessment, it invites caretakers to be part of the change process
and to be ‘change allies’ with the child (Freeman et al., 1997).
Encouraging caretakers to shift their own map boundaries - in terms of compassion
and understanding, relationship, or behaviour — can in turn free the child to make the
changes that they want. In some instances the adults must make a change before change
is a possibility for the child, e.g. an acrimonious divorce where parents’ hostility increases
pressure for their child to ‘take sides, or where a school has a too-entrenched negative
view of a pupil and cannot see the efforts she is making to change (see Example 1 below).

Example 1 Howa Change in Perspective for Adults Increases

the Possibility of Change for a Child
Simon is 10 years old. He is identified as the school ‘trouble-maker’ invariably at the
tail-end of a story of conflict and dispute. Early in the counselling preparation phase
Simon indicated that he was always in conflict with his brother and peers at school. He
was distressed by this, particularly how he was blamed as instigator on every occasion.
As a result Simon was feeling very down on himself, though few recognised this part
of him hidden behind the conflict. In the school’s opinion he was the trouble-maker.
During the pre-therapy assessment Simon identified how he wanted to both
change his behaviour and how he saw himself. He wanted others to think more posi- |
tively of him too. As part of the assessment the counsellor invited Simon’s teacher to
closely observe how many times he got into trouble and what led up to it. The teacher
was quite surprised to discover that Simon's behaviour was often a reaction to some-
one else's taunt. This change in outlook saw the teacher become more compassionate
towards Simon. She started to notice changes in his behaviour and encouraged him.
In turn this helped Simon to more frequently step back from situations of conflict. A
new story about Simon was emerging, possible only through the involvement of a
key adult during the preparation phase who was willing to rethink an established and
defeatist story that could have really hindered counselling progress.

As a young person increases in age there is less reliance on direct adult involvement
in recognition of their developmental capacity for increased autonomy and personal
 Preparations for Therapy: Beginnings 159

problem-solving. However, it is worth bearing in mind that young people may wish to
continue to involve parents/carers at key points in the work, especially where relational
difficulties are a source of distress (see Example 2 below).

Example 2 _ Re-connecting Family Relationships in the Face

of Suicidal Thoughts
Mark was 16 when he self-referred to the Barnardo's school-based counselling service
where he attends a school for pupils with mild to moderate learning disabilities. At his
first session Mark presented with high levels of emotional distress, finding it hard to
verbalise his thoughts and feelings. However, he was able to indicate that things had
got so bad for him recently that he had been thinking of taking his own life. Given
Mark's level of distress and his difficulty in articulating it, the counsellor tentatively
suggested completing the ‘young person's stress profile! Mark agreed and found it
useful to communicate and clarify his distress this way.
It emerged later that Mark greatly valued the relationship with his parents but felt it
had been going through a difficult patch lately. He began to identify this as a key con-
tributor to his current feelings of stress and isolation. Taking Mark’s lead, the counsellor
indicated it would be possible to meet with his parents in a counselling session. Mark
was very interested in this idea. The next session was a four-way conversation between
Mark, his parents and the counsellor. During the session the counsellor facilitated a
discussion about how much the whole family valued the close relationship they had
and the things they did together to maintain it. Mark also got to hear directly from his
parents what it was they particularly valued about him and their hopes for his future.
At the following session Mark completed the stress profile again only to find sig-
nificantly reduced scores. Mark saw the conversation with his parents as pivotal to his
change in personal outlook. Given Mark’s age, it would have been easy to overlook the
relevance of parental involvement in the counselling assessment.

Fifth Preparation Task: Integrating the Map of Standardised

Measures

Standardised measures are not incompatible with relational counselling practice. Using
them does not require counsellors to resolve a clash between the ‘art’ (relational prac-
tice) and ‘science’ (standardised measures) of preparation/assessment. Rather, it’s about
how to interconnect the more emotionally-distant, analytical perspective of a meas-
ure with the more inter-subjective, relational knowledge of a therapeutic conversation.
This interconnection enriches potential for a fuller understanding of all the assessment
160 The Handbook of Counselling Children & Young People

material. The counsellor’s task is to hold together the different - sometimes clashing -
emerging perspectives, while centralising the voice of the CYP.
Several standardised measures have gained prominence within UK CYP counselling,
namely the Strengths and Difficulties Questionnaire (SDQ) (Goodman, 2001) [avail-
able at www.sdqinfo.com] and the YP-CORE (Twigg et al., 2009).
The use of session-by-session measures has emerged as a key trend over the last five
years. Collecting outcome information at each session is a great way of gathering ‘prac-
tice-based evidence’ (PBE). Session-by-session measures improve effectiveness, reduce
drop-out and prevent deterioration (Duncan and Sparks, 2010) and, remarkably, with-
out asking counsellors to make any other changes to how they work. In addition to
the popular ten-item “YP-CORE; there is also a suite of measures called the Outcome
Rating Scale (ORS) (Miller and Duncan, 2006) which tracks distress/well-being and the
therapeutic alliance session-by-session. ORS is validated for use with young people 12
and up; there is a version for children aged 6-11 called the Child Outcome Rating Scale
(CORS) (Duncan et al., 2003), and one for children under six called the Young Child
Outcome Rating Scale (YCORS). Quick to complete and useful as a clinical as well as an
outcome tool, Barnardos Northern Ireland has used these measures in its school-based
counselling service since 2008. They are available at www.heartandsoulofchange.com,
and more information can be found in Stewart (2012).
Scoring the measure and sharing the result with the client - including an outline of
its meaning in relation to the clinical cut-off - provides a final reference point in the
collaborative preparation process. It further informs its outcome and decisions about
counselling suitability.

Sixth Preparation Task: Reviewing the ‘Assessment Meta-Map’

The endpoint of the preparation listening process will be the creation of a larger ‘assess-
ment meta-map. Therapist and client — including key adults with younger children — need
to review the meta-map together and agree on the suitability of counselling.

Seventh Preparation Task: Contracting

Ifa period of counselling is agreed a contract should be drawn up with the young client
covering the following areas:

1. Who will be involved? Agreeing the level and extent of systemic involvement (if any).
2. Where and when will the counselling happen?
3. What will happen in sessions? Outlining the range of approaches and activities the coun-
sellor can offer and ascertaining any immediate client preferences (e.g. sand-tray work;
psycho-education; therapeutic assessment game).
 Preparations for Therapy: Beginnings 161

4. Why might counselling be useful? Establishing focus/purpose/goals; this includes talk-

ing with younger children (4-12 years) about why key adults feel it would be useful and
checking this against their views.
5. What about confidentiality? Establishing confidentiality and its limits.
6. What about counselling records? Outlining the policy on record-keeping and gaining con-
sent from the young person (or parent/carer if not ‘Gillick competent’).
7. What about complaints? Outlining the complaints policy and agreeing whether a nomi-
nated ‘trusted adult’ is required to represent the child’s views.

Theoretical Underpinning

It is a pleasure to listen attentively to children because listening opens windows on

the child’s world. As therapists, as we accept their invitation to explore their world,
we quickly understand our dependency on them as our guides. This is because the
CYP’s understanding of their world differs from the adult experience in a myriad of
ways. I am reminded of the CYP who was exploring the experience of loss of a much
loved adult with a parent. The parent had explained euphemistically that the adult
had ‘gone to be with Jesus. The CYP thought for a little moment, and then helpfully
clarified, ‘So they’re in Bethlehem then. A charming anecdote or a sharp reminder of
the way children understand the world. Listening to the client involves not only what
our clients say but also being attuned to their age and stage of development. In lay-
ing the theoretical foundations for sensitive and autonomous therapy we believe that
focusing on developmental theories will provide clear signposting and guidance. We
would advocate a framework for integration of counselling theory and child-centred
practice as the basis for preparing CYP clients for therapy. We also believe that, given
the CYP’s embedding within their family system, it is essential to take the widest pos-
sible view of who and what needs to be prepared if children and young people are to
gain all they can from their experience of therapy. To assist us in laying a theoretical
basis for the work, we propose briefly to explore Piagetian theory, Bronfenbrenner’s
ecological systems theory, schema theory and the application of Vygotsky’s theories to
the process of preparation for therapy.

Age and Stage

Piaget asserted that childhood is not just quantitatively but qualitatively different
from adulthood as shown in the example given above. As the counsellor enters into
the process of preparing themselves for working therapeutically they must actively
engage with the age-appropriate aspects of the CYP’s voice. The counsellor must
be listening so actively as to hear variations in the range of development between
162 The Handbook of Counselling Children & Young People

children/young people within ages and stages. The counsellor must understand the
normative issues that development itself generates, whilst also being aware that every
child is part of a particular complex familial and societal system.

Example 3 Listening to the Developmental Voice

Samira, aged nine, self-referred to a school counsellor after her mother had slipped
into a diabetic coma in the early hours of the morning. Her mum had managed to
call the emergency services when she felt unwell. The police had to break into the
house and Samira was worried about her mother dying in the future. She had talked
to mum about this but mum said she was being silly. Mum felt Samira should be over
it by now and didn’t need counselling. Samira’s view of illness and death differed
markedly from her mum's. At nine, Samira was on the cusp of developing a more
mature concept of death and dying. She had begun to recognise that death is perma-
nent and irreversible and felt fiercely protective of mum and did not want to distress
her. Her mum had talked to her about diabetes as a manageable illness but Samira
was unable to understand this because she had not yet developed a scientific view
of illness as a process. Preparation for therapy involved acknowledging Samira’s fears
and concerns whilst helping mum understand the need for a safe place for Samira to
ask potentially upsetting questions and explore different ways of understanding how
human beings with illness survive with an intact sense of self. The developmentally
aware counsellor should be actively engaged with understanding development and
its effect on the client.

Individual Variation

Children and young people are not a homogeneous group, despite the fact that we often
talk about them as if they are. Individual children and young people differ markedly
from each other in temperament, experience, life setting, understanding and capacity to
process the many elements that represent the beginning of the therapeutic experience.
Practitioners and teams employ different skills and tools working across the age range
and we should be respectful of other ways of working than our own model. Counsellors
can also benefit from a more global understanding of how CYPs engage with tak-
ing information from their environment. Gardener's theory of multiple intelligences
alerts us to the fact that ‘the brain has evolved over millions of years to be responsive
to different kinds of content in the world. Language content, musical content, spatial
content, numerical content’ (Gardener, 1983). Learning styles theory also encourages
us to engage with the CYP styles of encountering the world, so preparation for therapy
 Preparations for Therapy: Beginnings 163

should include auditory, visual, read/write and kinaesthetic ways of introducing the
therapeutic process. CYP counsellors value the CYP client, their right to autonomy, and
to safe, sensitive and appropriate access to therapy that makes human sense to the client
(Donaldson, 1978). In order to ensure this, we must always take the CYP as our guide for
the start of the therapeutic process, committing to setting aside our adult assumptions,
frameworks and language. General history-taking and specific measures like YP-CORE
or SDQ can support this.

Context is Everything

Ecological systems theory illustrates the complex systems in which the CYP lives and
helps us conceptualise the interacting and reciprocal effects of these systems on the
client and counsellor whilst also allowing for change due to the impact of time (Figure
10.2). While Bronfenbrenner (1986, 2005a) does not offer a counselling theory, he
reminds us of the who, what and how of assessment and preparation as we engage in
the pre-therapeutic process.

soctoentcliele

Microsystem

The individual
Sex Age
Health etc.

Figure 10.2 Bronfenbrenner’s ecological model of development.

164 The Handbook of Counselling Children & Young People

Whilst children are regarded as autonomous beings from the counsellor’s per-
spective and within the BACP ethical framework, not everyone within the child’s
social system may understand or accept this. The counsellor may have a differing
view of autonomy from parents, social workers, teachers or other adults who have
an interest in the therapeutic process. The CYP may have an unexplored under-
standing of their autonomy. The counsellor may therefore need to prepare the CYP
or others within the setting for this. Views of autonomy and control may differ
between the multi-disciplinary team in a school or CAMHS. Theoretical orientation
may also place demands on how counsellors prepare CYPs for therapy work. The
counsellor should also move beyond this normative preparation by engaging with
the legal and ethical framework within the CYP’s system. In doing so the counsellor
must hold the CYP’s needs and rights as paramount. In practice this is rather like
engaging in a complex multi-player video game in which the counsellor is central
because it involves the counsellor in mediating intra-personal issues like competence,
capacity and consent, interpersonal issues such as risk, safeguarding, confidentiality,
and societal issues like legal requirements regarding disclosures, role limits and
boundaries. For example, CYPs can often disclose safeguarding issues at assessment.
As many young video gamers tell us, when dealing with complexity, a clear, simple
plan is often best. Therefore many of these issues can be dealt with at the outset of
the preparation for therapy phase by clear communication with the CYP, their car-
ers, and any other interested parties, for example social services.

Example 4_ Holding the Client Central

Cody is a 15-year-old boy who has cancer. He and his parents know that his disease is
terminal. He has been offered a place on a palliative drug trial which may extend his life
_ bya few months. His parents desperately want him to agree to the trial and have asked
him to spend time considering this in counselling. Cody has made it clear that he has
made the decision to decline taking part in the drug trial. He wants to spend his time
in counselling discussing how to tell his parents and plan for the last months of his life.
Cody's case is just one example of many where competing expectations, hopes,
needs, desires and interests can benefit from open, thoughtful and honest prepa-
ration for therapy. Preparation for therapy involves the counsellor in the process of
actively engaging with competing interests whilst advocating for the client. It requires
counsellors to use age-appropriate, high-level skills to establish excellent psychologi-
cal contact with the client. Once this has been established, respectful, collaborative
assessment of the CYP’s developmental ability and potential, reasoned professional

(Continued)
 Preparations for Therapy: Beginnings 165

(Continued)
judgements about their ability to understand and consent to counselling, and hon-
est communication can be entered into. Only by doing so can we ensure that young
people have opted to attend counselling freely (not because mum, dad or their social
worker felt it would be good), understand the consequences of counselling and can
openly speak and own the therapeutic space as theirs. Through a process like this _
_ Cody was able to own the counselling space and his parents were helped by him to _
let go. Preparation for therapy for the parents was an essential adjjunct to this process.

Developing a Schema for Therapy

CYPs, carers and other interested adults usually have no idea of what counselling
is. Just as we have no schema for astrophysics (unless somebody helps us acquire
one!) so CYPs, carers and interested adults need the counsellor to help them
develop a schema for therapy. It is therefore the role of the counsellor to provide
a window into the world of therapy. This builds engagement and provides a narrative
for the process. Clear information leaflets and website statements need to be
offered. Pre-therapy conversations need to be had with CYPs and adults that
emphasise that the CYP, and not the parent or carer, is the client. Clear, picture-
based, verbal, age-appropriate descriptions of what counselling is, and is not,
need to be provided for CYPs and interested others (Arnold, 2010). Expectations
on all sides need to be elicited and explored. In Cody’s case this was essential. To
do this a counsellor may meet with the CYP and with parents either separately or
together in pre-therapy. Interested adults need to be freed up from the ‘counsel-
lor as fixer’ paradigm because CYPs are not ‘broken. They are themselves and
we respect them as such. Counsellors also need to establish clear confidentiality,
safeguarding and risk boundaries to the preparation for therapy schema so that
young people are not shocked or disappointed when, during or after assessment,
a counsellor must report a disclosure or take action because a CYP is at risk of
significant harm. A positive view of standardised and session-by-session measures
should be built from the outset. We are strongly of the opinion that measures are
there to resource the client in their understanding of self, change and develop-
ment. However, in order for the client to be positive the counsellor must have
honestly explored and engaged with their barriers and biases to the use of such
resources. It is fascinating to see even very young clients take skills they have
learned, to develop positive personal evaluation skills that build their confidence
in school, with friends or at home.
 166 The Handbook of Counselling Children & Young People

Preparing for Good Outcomes — The Zone of Proximal

Development (ZPD)

This leads us to the final girder in our theoretical underpinning of preparation for
therapy. Vygotsky (1934) postulated that the work of development can be described
as the acquisition of cultural tools. As counsellors we might describe the process as a
gateway to more useful ways of being for the client. He postulated that understanding and
meanings are acquired through interactions between adults and children and that this
begins ‘first as an interpersonal process before it appears in the child as an intrapersonal
process’ (Vygotsky, 1988, cited in Lee and Das Gupta, 1995: 13). He also introduced the
concept of the ZPD (Vygotsky, 1934). This means that children can get a certain way
on their own initiative but the presence of a respectful, listening and engaged adult
increases the child’s developmental reach. The difference between where they are and
where they can get to is the ZPD. This is the counselling space.

Summary

e A‘collaborative assessment is essential for safe and effective preparation for therapy with chil-
dren and young people
e There are seven key collaborative assessment tasks that make up a‘preparation-for-therapy’
map:

i. Pre-preparation (therapist and therapy environment)

ii. Facilitating a personal preparation-for-therapy map with a child/young person
iii. Mapping risk
iv. Mapping the context
v. Integrating outcome measures
vi. Reviewing the assessment ‘meta-map’
vil. Contracting

¢ Counsellors should have a working knowledge of developmental theory if they are to pro-
vide safe and effective therapy
¢ Counsellors need to draw on this knowledge in order to tune into the age and stage of
each client’s developmental presentation
e Children and young people are not a homogeneous group and the counselling approach
should reflect awareness of ‘multiple intelligences’ and cater for a range of ‘learning styles’ -
visual, auditory, read/write, and kinaesthetic — to help scaffold a schema for therapy
e In the presence of a respectful, engaged and attuned therapist the counselling space can
become a ‘zone of proximal development’ for children and young people where they can
extend their developmental reach and make positive life changes
SG
 Preparations for Therapy: Beginnings 167

Reflective Questions

Reflection 1

The purest form oflistening is to listen without memory or desire. (Wilfrid Bion, 1897-1979)

How might the counsellor’s experience of their own childhood or their experience of
parenthood have an impact on their understanding of how to prepare children, young
people and parents for the experience of therapy?

Reflection 2

The process of counsellor reflection is vital to preparing ourselves for undertaking

therapeutic work with any client group. It is particularly important in working with
children and young people because the counsellor may find themselves ‘staring into
the mirror of (their) own grief’ (Formica, 2009). A consideration of the potential for
parallel processes in the room can and should be explored when a referral is first made.
What memories or desires might I need to deal with?

Reflection 3

What knowledge, skills, attitudes and values do I have in assessing the capacity, com-
petence and ability of CYPs to give consent to counselling? What knowledge and skills
do I need to acquire? What personal and professional attitudes and values do I need to
reflect on and process, to assist myself, children, parents and other concerned adults in
the process of understanding the autonomy of children and young people?

Sam en a a ee ee ee ee ee ne ea
®

Learning Activities

Activity 1 - Hearing Your Own Voice

Record yourself explaining the process of counselling to a child, adolescent, parent. Play it
back and reflect on what you have learned from listening.

Activity 2 - Preparing the Setting

You are a counsellor in a school setting. A teacher comes to you with the dilemma below
and asks for advice. A client’s parent has made it explicit that they want to withhold consent
for their 14-year-old to attend counselling. The young person is clear in their own mind that
(Continued)
x
x
168 The Handbook of Counselling Children & Young People

naa wT ee ee eee eee eee SS eS eee

——
é
(Continued)

they do wish to attend. What processes would you as a counsellor have to undergo to pre-
pare yourselftowork with this situation? What might you as a therapist be able to say to the
teacher, the young person, the parent, that might add clarity to the pre-therapy process?

Activity 3 - Preparing the Client

Consider the following clients:

An eight-year-old who is described by a parent as being very anxious

A 14-year-old newcomer who is a refugee from ethnic violence

A 10-year-old who has been exposed to domestic abuse at home

A 15-year-old who is wanting to explore issues around gender identity and sexuality

What preparation might you need to set in place that is specific to these clients as you
consider working with them?
ca &

Further Reading

CYP Counsellors require a developmental meta-rationale for how they begin, engage in and work
with their clients. Learning about development as a precursor to preparing for therapeutic work is
both a joy and a challenge. For CPD reading on development we would recommend:

Music, G. (2011) Nurturing Natures: Attachment and Children’s Emotional, Socio-cultural and Brain
Development. Hove: Psychology Press.
Santrock, J. (2010) Child Development:
An Introduction. New York: McGraw Hill.

For texts related to counselling assessment we recommend:

Lowenstein, L. (1999) Creative Interventions for Troubled Children and Youth. Toronto: Champion
Press.
Sharry, J. (2004) Counselling Children, Adolescents and Families. London: SAGE.
 Preparations for Therapy: Beginnings 169

Online Resources

BACP website: www.bacp.co.uk/ especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially modules CM 0103: Presenting
Issues and CM 06: Using Measures.
 The Therapeutic Alliance and
Counselling Process
Mark Prever

This chapter includes:

SRE ORE REBELS ST TEESE NOS ESSTEEIEEE ESD TITEL EESILEGEETEBE LEESES DIE EEELEL ESSE DELLE LEE LS LLL ELIE LE,

e Therapeutic alliance
e Counselling process and the middle stage
e Monitoring client process and progress

Introduction

This chapter explores the concept of the ‘therapeutic alliance; so critical in counselling,
but especially so in work with children and young people. When I go to meet a new
young client, it is the issue that concerns me most. Will I get on with this young person?
Will I be able to establish a climate of trust and respect? Will we agree as to what counsel-
ling is for and, ultimately, will they like me and I like them? In essence, will we get on? In
a sense, I am expressing concern about my ability to establish an alliance which ensures
that therapy can take place and, without which, any attempt at growth or change is near
impossible. The relationship we build with clients impacts on the counselling process
and the client’s process and progress. Although this chapter overlaps with some of the
material from other chapters, the material is focused in relation to: the therapeutic alli-
ance, counselling process and the middle stage, monitoring client process and progress
 The Therapeutic Alliance and Counselling Process 171

Therapeutic Alliance

The therapeutic alliance may also be referred to as the ‘working alliance’ but, put
simply, the therapeutic alliance indicates the degree to which the child or young client
trusts and believes in the counsellor and whether they ‘like’ them or not. It refers to
the collaborative aspect of the relationship between a young client and their counsel-
lor. Forming such an alliance is especially important when working with children and
young people who may come for counselling having already experienced a range of
‘interventions, where a therapeutic outcome has been second to behavioural or attitu-
dinal change.
The importance of the relationship in therapy and counselling with children and
young people did not begin with Carl Rogers, although his substantial work remains
a very important component and the essence of any discussion about the relationship
between client and counsellor. In his seminal article published in 1957, Carl Rogers set
out his understanding of the relationship in therapy as well as its centrality. The ‘condi-
tions of therapeutic change’ influenced all his subsequent works and the development of
what later became known as ‘person-centred therapy. Rogers argued that therapy is less
about what the therapist does to a client and more about the quality of that relationship
and the therapeutic conditions, which he felt were essential in any therapeutic work.
These were defined as empathy, unconditional positive regard and congruence; that is,
being yourself, non-judgemental and real with a client. It is worth noting that empa-
thy is seen as an important component of the therapeutic alliance across all models of
counselling theory and practice (Feller and Cottone, 2003). Rogers also emphasised the
need for what he termed ‘psychological contact’ by which he meant that both client and
therapist need to be aware of the presence of each other for a relationship to occur. It
is hard to see how a therapeutic alliance can be formed with a young client where such
contact does not exist.
The concept of the therapeutic alliance has its roots in psychoanalytic theory with
its emphasis on the transference relationship between therapist and client where the
work is based around the client’s previous experiences of relationships such as with
parents or significant others. A comprehensive and detailed history of the concept of
the therapeutic alliance can be found in Horvath and Luborsky (1993). This analysis
stretches as far back as to the work of Freud where, according to the authors, he makes
reference to the analyst maintaining ‘serious interest’ in and ‘sympathetic understand-
ing’ of the client to allow for the client to attach themselves positively to the analyst.
Greenson (1967) has also added to the discussion around the concept of the working
alliance in psychoanalytic theory (see also Kanzer, 1981). Focused discussion of the
concept begins with the work of Bordin (1979), who suggested that the working alli-
ance in therapy was comprised of three elements: tasks, goals and bonds. These were
later developed by Dryden (1989), who included a new component, ‘views, which he
172 The Handbook of Counselling Children & Young People

felt should be included in any expanded discussion of the therapeutic alliance. Bordin
believed that the therapeutic alliance was an essential component in counselling and
was possibly the most important factor in bringing about change in the client.
Goals are the outcomes which the client and counsellor have agreed to work towards
together. In other words, a mutual understanding of what might be causing the client's
problems or unhappiness. Such an agreement is more likely to lead to a successful out-
come for the client. In contrast, differences in expectations and understandings with a
young client or where the counsellor has a different agenda or is under pressure from
an organisation having been sent a particular role in relation to the counselling, which
is different to the client’s, is likely to undermine a successful outcome.
Tasks are the things that the counsellor actually does to help the client achieve their
goals. Again, these may be problematic where there has been a lack of contracting with
the young client or where there are misunderstandings around the way the work will
proceed.
Bonds refer to the interpersonal and are harder to describe but will include respect,
trust and hope. These themes are well developed in the person-centred literature.
Dryden (1989) sees the client’s attitude to the counsellor as important. This might
include things like trust in the counsellor and feelings of safety in the relationship. He
also refers to the client’s faith in the counsellor to bring about change in their lives. He
notes that clients will often bring with them to the counselling room ‘pre-formed
tendencies’ which have the potential to impact markedly on the counselling process.
His reference to ‘client reluctance’ may be relevant to work with children and young
people who may have developed preconceived ideas about adults in their lives and
whether they can invest trust in them.
Dryden is clear that the establishment of a therapeutic alliance is most likely to occur
where the views held by both client and counsellor are convergent, and where they are
not they need to be explored as part of the counselling work. Views held by both client
and counsellor around issues such as the nature of the client’s problems, how these are
best addressed and how this will happen also require exploration leading to common
understanding.
In drawing on the work and extending it to children and adolescents, Campbell and
Simmonds (2011) found that empathy and trust were highly valued by young people as
bond indicators whilst an additional parental support dimension was identified as of
particular importance, especially where the counsellor was able to show understand-
ing, reassurance and support. It is not surprising to find that research has shown a
strong correlation between the establishment of an effective working alliance and ‘suc-
cess’ in therapy. An excellent and detailed analysis of the arguments around this can be
found in Muran and Barber (2010). Equally, it follows that where there are obstacles to
the establishment of an effective working alliance, client progress will be limited — if,
indeed, the child or young person continues to regularly attend sessions. Most research
 The Therapeutic Alliance and Counselling Process 173

into the therapeutic alliance has related to work with adults, but this is changing, and
some useful papers can be found in the further reading section below.
So what can hinder the therapeutic alliance? Ackerman and Hilsenroth (2001)
looked at the personal attributes of the therapist which might interfere with the thera-
peutic alliance. These included: rigidity; uncertainty; being critical, distant, tense and
distracted. He also noted that the therapeutic techniques of the counsellor were an
important factor and a negative influence on the working alliance where sessions were
over-structured, where there was inappropriate self-disclosure, an over use of trans-
ference interpretation and an unhelpful use of silence. In recent years there has been
increasing academic discussion around the concept of ‘ruptures’ or a ‘weakening’ in the
therapeutic alliance and their repair. Interested readers might want to look at Eubanks
et al. (2010) and Safran and Muran (2000). We know when a therapeutic alliance has
been established with a young client; we have a sense that our young client is engaged
with the process, and we seem to understand each other. The client is open and appears
to trust us. We have a feeling that progress is being made. We feel a sense of rapport
and that we are doing what we are meant to be doing. Conversely, where there is a lack
of understanding and communication between counsellor and young client, it is likely
that a working alliance has not been established. Where the client becomes frustrated
with the counsellor expressing anger or anxiety or, indeed, a lack of interest, it might be
suggested that the working alliance is in difficulty.
Returning to the influence of Carl Rogers, there exists a consensus that regardless of
counselling orientation, it is hard to see how without the ‘core conditions’ a therapeutic
relationship can be established. It doesn’t matter how much training a person has done
or what counselling qualifications have been achieved, it is difficult to see how these
professional developments alone are sufficient for the building of a therapeutic work-
ing relationship. This is even possibly more marked when working with children and
young people who may already have suspicions about professionals and who desire a
helping relationship that is characterised by warmth, acceptance, trust, realness and an
empathic ability to feel what they are feeling.
My own experience of working with children and young people has shown that
a therapeutic alliance is more likely when the counsellor is able to remove issues of
power and authority and bring some equality and mutual respect into the relationship.
Other important dimensions to the relationship are that it should be characterised by
warmth, friendliness, honesty, openness, a lack of judgement, real empathy, showing
energy and interest in the child and their story. Children and adolescents need to feel
that their counsellor is a real person and not somebody in a role.
Bryant-Jefferies (2004: 6-7) draws our attention to the work of Everall and Paulson
(2002) and their 2002 study which focused specifically on the needs of adolescents.
Based on a series of semi-structured interviews, three themes were explored in relation
to the therapeutic alliance: therapeutic environment, uniqueness of the therapeutic
174 The Handbook of Counselling Children & Young People

relationship and therapists’ characteristics. They observed that a therapeutic alliance

was characterised by acceptance, supportiveness, trustworthiness and the appropriate-
ness of the therapeutic tasks and goals. Bryant-Jefferies notes how it is important for the
young client to see the therapeutic relationship as special, and indeed the counsellor as
their ‘special friend’, and the relationship experienced by the young person as being dif-
ferent to those normally experienced with an adult. In this sense, there is the expectation
that the counsellor will adapt their working style to suit the age of their client.
At the relational level, I believe that it is important that the counsellor can help the
client to find a sense of meaning and hope, allow the child to talk about what is impor-
tant to them and not show frustration or impatience when the young person has lost
hope, is sad or despairing. The literature reveals an acceptance that the therapeutic
alliance or its equivalent is an essential part of any therapeutic work, regardless of ori-
entation or modality. Muran and Barber (2010) refer to Wolfe and Goldfried’s (1998)
description of it as ‘the quintessential integrative variable and most quoted ‘common
factor’ in psychotherapy as discussed by Wampold (2001). However, they also refer to
a growing number of writers who have challenged this assumption or see the matter as
being of greater complexity than first understood. Some of these points are explored
in the literature listed in Further Reading. You will also see I have included a growing
body of work around the therapeutic alliance in relation to children and young people
that had previously been largely neglected.

Counselling Process and Middle Stage

Whilst it is possible for the therapeutic alliance to be established in a first session with
a child or young person, for others it may occur over a period of time. It is equally
important to note that once this alliance has been established, it does not remain static
or established’ but will continue to develop and deepen in what might be referred to as
the ‘middle’ stage of counselling. For an analysis of the therapeutic alliance over time,
see Stiles and Goldsmith (2010).
Gerard Egan's (1998: 190) successful books set out clearly a model of counselling where
there are clearly identifiable steps towards helping people to become more competent in
helping themselves in their everyday lives. However, not all counselling modalities see
the counselling process structured in such a formal way. In a person-centred approach
for example, the counsellor does not see the client in such definable ways. Mearns and
Thorne (1988: 190) write: ‘Instead, she recognises that each client is unique, and that the
therapeutic process he experiences will be different from any other individual’
However, Mearns and Thorne do recognise that counselling is a ‘process’ and under-
stand that in the middle phase of counselling relational depth should develop alongside
an increase in trust. They also see the middle stage of counselling as being characterised
 The Therapeutic Alliance and Counselling Process 175

by increasing intimacy, the creation of a sense of mutuality and increasing self-acceptance

by the client. As the counselling develops with the young client, we might expect to
see a deepening of the relationship which may offer the counsellor more confidence to
challenge the young person and a willingness by the young person to accept these kinds
of interventions. As the counsellor displays qualities of acceptance, the young person
may be more inclined to take risks and show a preparedness to explore and express
feelings which may be difficult or disturbing.
In my work as a supervisor with counsellors who work with children and young
people, it is not uncommon for counsellors to refer to a feeling of ‘stuckness’ to emerge
within later sessions and either a sense of ‘going round in circles’ or for the work to
appear to regress. It is at this time that counsellors can sometimes question the process
or their own skills. Nelson-Jones (2002: 255) refers to the dangers of the middle phase
of counselling experiencing ‘session drift’ where the work with a client becomes aimless
with little progress being made. Counsellors working with young people may increase
the pace of the counselling during this phase, depriving future sessions of their rightful
place in the counselling process.
Horton (2000: 126) notes that the middle phase of counselling is usually the most
lengthy. This is not surprising as it can be seen as the work phase, when problems are
clearly defined and hopefully worked through. It is also where ‘unexpected memories,
discoveries and obstacles, crises and ambivalence or defences may arise’.
Horton (2000) goes on to describe a number of process goals of this middle phase
of counselling, which include: seeing patterns and important themes, affirming and
using the client’s strengths to help the client move towards new perspectives, leading
to increased self-awareness and ultimately new ways of thinking, feeling and behav-
ing. The problem with seeing the middle phase of counselling as the primary working
phase is noted by Nelson-Jones (2002) because it detracts from the working potential
of the beginning and ending phases. The middle phase of counselling with children
and young people will of course be affected by the orientation of the counsellor. The
centrality of the relationship as a necessary aspect of change within a person-centred
approach has been explored above. In their book Cognitive Behavioural Counselling
in Action, Trower et al. (1988) clearly set out a three-stage model where the first is
concerned with getting started, while the final phase seeks to develop independence.
The middle phase, with which we are particularly concerned here, has a focus around
the client learning the method of change inherent in the CBT process and theoretical
framework.
In psychodynamic counselling, the middle phase is more likely to focus on the
relationship between counsellor and client. This may involve exploring defences,
transference and feelings, behaviours and patterns of thinking, which may be con-
tributing to the client’s problems. Holmes (1999: 35) looks specifically at the role of
the relationship in relation to psychodynamic work. He suggests that people who
176 The Handbook of Counselling Children & Young People

turn to a psychodynamic counsellor often have relationship difficulties and therefore

these can be addressed through the relationship between counsellor and client. He
argues that the relationship itself becomes the ‘object of scrutiny and a vehicle for
change’. He accepts that the approach does also attempt to address issues outside of
the therapeutic relationship but, ultimately, the ‘principles learned’ will appear within
the counsellor-client relationship. In this way, whilst the nature of the therapeutic
alliance within the psychodynamic field may be different, it remains crucial if there is
to be sufficient trust to allow the client and counsellor to explore what Holmes refers
to as the ‘key to change.
Gaston et al. (1995) offer us an interesting insight into the therapeutic alliance from
three differing theoretical orientations, that is: cognitive-behavioural, psychodynamic
and experiential. The aim of their work was not to arrive at some ‘true definition’ of the
alliance, but to explore similarities and differences of the alliance from three theoreti-
cal perspectives. In a similar way, the middle stage of counselling will be influenced by
the number of sessions. Time-limited counselling has become more common where
sessions are being paid for and formed as part of a service-level agreement by an organ-
isation such as a company, or in the case of children or adolescents, in a school or
youth setting. The reality is that for those working with young clients there is now an
increasing pressure of time in terms of the number of sessions or, indeed, the length of
sessions. Some schools may expect a session with a student to last around 30 minutes,
which is hardly adequate for quality work to take place.
Feltham (1997: 1-28) offers a fascinating insight into the relationship between time
and counselling. He challenges the criticisms made of time-limited counselling which
assert that the result is a far more superficial activity than long-term or open-ended
work. Feltham recognises that despite the time set aside for counselling, most models
revolve around the idea of sequential stages, which include a beginning, middle and
end. Indeed, it could be argued that all human encounters follow this process, whether
they are long or fleeting. Feltham also suggests that the essence of all modalities is that
the counselling offered in some way allows for a number of therapeutic processes to
take place, thereby accelerating the change or improvement that might have occurred,
had that passage of time been unaided. In his book, Feltham explores a range of argu-
ments for and against the move in the profession towards time-limited work. Whilst
these are interesting, we do not have the time or space to discuss them here. However,
he does suggest that all counselling is time-limited in one way or another. There may
exist a danger that a young client may feel unable to explore serious issues where time
is limited, or as Feltham draws our attention to the arguments set out by Rowan (1993),
where he suggests that it threatens to ‘short-change’ clients, ‘robbing them of the deeper
layers of work on themselves they may need. In a sense, the argument here is that this
is all academic, since whether our work with children and young people is short-term
or time-limited, it will still have a beginning, middle and end.
 The Therapeutic Alliance and Counselling Process 177

Monitoring Client Process and Progress

Counsellors working with children and young people often want to carry out regu-
lar reviews with their young clients as a way of informing the counselling process,
measuring the health of the therapeutic alliance and, indeed, the effectiveness of the
counsellor’s work in the room. Reviews provide the counsellor with important indica-
tors as to whether the client is making progress, is experiencing the counselling as a
positive and useful intervention and whether the child’s needs are being met.
Reviews may be important because, as counsellors, we cannot assume we are offering
the young client the kind of help they need at this particular time in their life; this would
be our perception alone and there has to be some discussion. Reviewing in this way gives
the client a sense that their views matter and they are part of a relationship and not simply
on the end of another adult helping intervention. Client reviews with children and young
people often ask the young client to comment on matters such as counsellor behaviours
which they find helpful, or not, whether sessions are enjoyable and meaningful and
whether they feel able to talk to their counsellor about their most difficult feelings. By
stating from the start that reviews will be carried out periodically, the young client sees
these times as natural and part of the process as opposed to an adjunct, which might
have the feel of assessment. Indeed, some counsellors keep review informal and they are
smoothly slipped into sessions and are therefore less threatening to a young client. Some
counsellors find the idea of reviewing their work with children and young people not
necessary, either because they feel they are monitoring feedback from the client throughout
the counselling, or because they feel that it interrupts the flow of the work. It has been
argued that formal reviews do not provide useful information about the feelings of their
client as young people are more inclined to show conformity and not want to upset their
counsellor. They may feel that negative feedback might lead to the ending of the contract
and that the work is likely to finish as a consequence. For an overview of the process of
reviewing therapeutic progress in counselling, see Sutton (1997).
If one function of a review with a young client is the monitoring of client progress,
then it is important to be clear about what we are actually measuring. I have written
elsewhere (Prever, 2010) about the difficulties associated with measuring outcomes in
therapy with children and adolescents. Voluntary agencies keen to attract funding are
required to show client progress whilst service-level agreements mean that the receiving
organisation often needs to provide evidence of change. Often, organisations will use
scaling systems that enable comparisons of clients’ perceptions of progress over time.
However, just because a young client's scores may not have improved is not necessarily
an indicator of the counselling being ineffective, as the client might have deteriorated
had counselling not been offered. It is also clear to me as a counsellor that much change
will be at an emotional and feelings level often associated with new insights and mean-
ings rather than overt behavioural changes often demanded by funders. It may also be
 178 The Handbook of Counselling Children & Young People

possible that the effects of counselling will not be felt immediately but returned to in
later months and years as a personal resource. This is not of course to suggest that regu-
lar reviews designed to monitor change and progress in our young clients should not be
attempted, but rather an indicator that any such reviews should be used with caution
and in the context of the wider counselling work with the child.
The most widely used review tool is The Young Persons Clinical Outcomes in
Routine Evaluation (YP-CORE). The measure consists of 10 items to be used by
11-16-year-olds and is easy to administer. The items which are completed by the
young person focus on areas subject to change and invite the young person to respond
on a five-point scale. YP-CORE is designed as an outcome measure but can be used
regularly in sessions to measure change and progress. A description of the rationale
and development of YP-CORE can be found in Twigg et al. (2009) and is discussed
elsewhere in this book.

FR Or cha
Case Study Aaron
Aaron is 12 years old and lives with his mother, Diane, and new stepfather, Colin. This is a relatively
new arrangement, perhaps only six months after his previous stepfather, Dean, had been forced to
leave home as part of an informal arrangement with social workers. Aaron has a sister and younger
brother — Rebecca, who is 15 years old, and Ben, aged seven. Mum is also expecting a fourth child. It
is likely that Colin and mum will marry in the near future.
Aaron and Rebecca have had almost no contact with their biological father, who left home within
18 months of Aaron being born. Dean was convicted of a physical assault on Rebecca that had been
described by the judge, in court, as particularly vicious.
There had been a history of domestic violence in the family from the outset and police had been
called to the home on numerous occasions. Both children had witnessed some very brutal attacks on
mum and both children had been offered counselling at school but only Rebecca had taken up the
offer of this kind of support. However, this work was short-lived.
The attack by Dean on Rebecca was outside the norm, since all of Dean's attention had previously
focused on mum. Dean claimed in court that he was only disciplining Rebecca for her rudeness to
her mother after an argument around keeping her room tidy and staying out late. However, the court
had decided that the ‘discipline’ was indeed beyond acceptable and had occurred over a period of
time and had the feel of a ritual. There was a suggestion that persistent alcohol and substance misuse
had been a factor in the assault and, whilst not raised in court, professionals working with the case
had agreed that there may have been a sexual element to the attack.
Rebecca’s behaviour and achievement at school had deteriorated and staff at her school were
already concerned before she began cutting her wrist and arm. The cuts were superficial and caused
by a paper clip and later by a pencil sharpener blade, but sufficient to alarm her friend Eva, who
 The Therapeutic Alliance and Counselling Process 179

Ge... pastoral staff at the school. It was events around this that resulted in the school making a
child protection referral, after which further disclosures were made.
Aaron's behaviour had already been affected by the domestic violence he had witnessed, but the
trauma suffered by his sister had resulted in Aaron fighting at school, rudeness to staff and his even-
tual ‘managed move’ to a nearby school. An attempt to allocate a mentor, Steve, to work with Aaron
to address his unwanted behaviours proved brief and fruitless.
By the time Aaron was referred to a counsellor by his social worker he, like his sister, had been
involved with a large range of professionals. In addition to children’s services in the borough, Aaron
had been involved with a number of behavioural support workers and a range of behavioural
interventions had been introduced by his head of year. There had also been an assessment by an
educational psychologist when suspicions had been raised that he might have some characteristics
associated with ADHD. When Aaron was referred for counselling at a voluntary youth counselling
agency, he had no sense of what counselling was. Whilst he agreed to the counselling, no one had
explained to him what these sessions were for. He believed them to be ‘compulsory’ as a way of
avoiding yet another move to a new school or alternative provision. Aaron turned up to his first
counselling session accompanied by his mother, who insisted on explaining to Hamza, the counsel-
lor, why Aaron needed to be there.
Hamza, having read the referral notes, knew that establishing a working therapeutic alliance with
Aaron was going to be difficult. In the first session, Hamza experienced Aaron as polite, pleasant, and
not quite as described in the notes, which had emphasised aggression and anger. However, what was
clear to Hamza was that Aaron could not see the purpose ofthe counselling if, indeed, he had an idea
of what to expect. Hamza was also aware of the many professionals who had played a part in his life,
but his arrival at the agency suggested that very little therapeutic work had been carried out; rather,
there had been attempts to modify his behaviour which had been causing so much concern. Hamza
felt no connection with Aaron and it was clear that, if the work with Aaron was to be meaningful,
then a working relationship needed to be established.
Aaron shared few common goals, or any joint understanding or purpose to the work. At this stage,
Hamza was wrestling with the uncomfortable feeling of not liking Aaron, as all attempts at inviting
him to speak resulted in only a few words, leaving Hamza feeling de-skilled and doubting his own
abilities as a counsellor. Hamza discussed with his supervisor his frustrations in working with his
young client and how he felt he was becoming increasingly rigid in his approach, more inclined to
resort to ‘techniques’ and questions, disinterested, aloof and distant.
In the third session, Hamza decided to re-establish the contract discussed in the first session. He
said that he reassured Aaron that there was no expectation that he would talk about his very painful
past. He said that he recognised that a lot of adults had tried to help in the past and had possibly let
him down. Hamza made it clear that he was not here to change Aaron's behaviour unless he wanted
that too, but stressed that this was Aaron’s time and he could talk about anything he wanted to. As
Aaron began to disclose a little more in each subsequent session, Hamza worked hard not to make

2
(Continued)
 180 The Handbook of Counselling Children & Young People

_
(Continued)

any judgements about what others had classed as anti-social behaviour. He strove to communicate
to Aaron that he was genuinely interested in him as a young man and not as a‘case’ As Aaron opened
up a little more, Hamza saw glimpses of the hurt and anger that his young client had previously been
unable to express.
By the middle stages of counselling, Hamza described in supervision how he felt a sense of rapport
and warmth towards Aaron. Perhaps most importantly, Hamza believed that trust had been estab-
lished. It would not be true to say that this trust was never tested, because it was. School holidays
were a problem, as it sometimes felt that the therapeutic alliance had been lost in some way and
needed re-establishing each time. From initial assessment through a series of periodic reviews, there
was a Clear sense that progress had been made and the feedback from Aaron was that the counsel-
ling was ‘useful for getting your feelings out’.
The sessions shared by Aaron and Hamza lasted for 16 sessions. It was clear to Hamza that more
work was yet to be done, but he recognised that at this time this was the limit for Aaron, and he had
shared all he could at this particular stage in his life. Aaron continued to experience a range of dif-
ficult emotions, of which guilt at not protecting his mother and sister was paramount. He remained
confused, torn, angry and feeling helpless, but possibly a little more in control of what had felt decid-
edly out of control. Hamza hoped that Aaron would have further opportunities for counselling and
that the trust and common understandings, beliefs and warmth shared could be carried over into
any new counselling relationship. J

Summary

e This chapter has shown that the therapeutic alliance is critical to any work with a child or
young person. Without this qualitative aspect of the therapeutic relationship, counselling with
a young client becomes something else. Whilst different models of counselling place a differ-
ent emphasis on the importance of this relationship, most see is it as an essential component
and pre-requisite for therapy
e The chapter has also shown that as counselling moves through a number of phases, the thera-
peutic alliance has to be maintained and nurtured to ensure that client and counsellor remain
in contact with each other and with some shared understanding of the work and the way an
outcome can be achieved, whatever form that takes
e Whilst many organisations working with children and young people are required to submit
detailed statistics on the work ofthe service as a whole, individual reviews with clients provide
the kind of feedback and mutual exploration for the work to grow and develop
 The Therapeutic Alliance and Counselling Process 181

Reflective Questions

1 Are there differences in the nature of the therapeutic alliance

when working with children and young people and with adults?

You may want to read the first chapter of this book on development and attachment.
Children and young people relate to adults differently, dependent upon their stage of devel-
opment and previous experiences of attachment. The counsellor will need to focus on
building up trust and being aware of power dynamics related to the counsellor and client.

2 In your work with young clients, how would you know if a strong
therapeutic working alliance had been established?

You would be monitoring the relationship through the risks the young person was
taking in sharing their material. If they share easily and have built up this through
gradually sharing more personal and revealing material, you can be sure that the ther-
apeutic relationship is strong. A child or young person may act out within a strong
relationship to test the boundaries.

3 How might a counsellor working with a child or young person

build trust?

Think around the development of the counselling contract and the limits of confiden-
tiality. If a counsellor is to be trustworthy, they will need to keep to the contract, stick
to boundaries and be accepting and unconditional in the relationship.
a a ee ee ee ee ag ee ge ese eee a ee eae
s

Learning Activities

1. Think about and describe examples from your own practice where you have felt a rapport
and common sense of purpose with a young client. Also, a time when there were barriers
to establishing a therapeutic alliance; were these difficulties overcome and, if so, how?
2. If you have personally been in the role of client, reflect upon your experiences of the
therapeutic relationship, or otherwise. What were your feelings at this time?
3. Consider some of the cross-cultural dimensions to the establishment of the therapeutic
alliance.
¢
ee eee
182 The Handbook of Counselling Children & Young People

Further Reading

Clarkson, P. (2003) The Therapeutic Relationship. London: Whurr Publishers.

Cooper, M. (2009) The young person’s CORE: Development of a brief outcome measure for young
people. Counselling and Psychotherapy Research 9 (3): 160-168.
Feltham, C. and Horton, |. (2000) The SAGE Handbook of Counselling and Psychotherapy. London:
SAGE.
Levy, S. (2000) The Therapeutic Alliance. Madison, CT: Psychosocial Press.
Mearns, D. and Thorne, B. (2013) Person-Centred Counselling in Action. 4th edn. London: SAGE,
chapter 8.
Nelson-Jones, R. (2002) Essential Counselling and Therapy Skills: The Skilled Client Model. London:
SAGE, chapter 12.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd website: http://counsellingminded.com,
especially: MN 12.01:Empowerment,
Activation, and Tackling Passivity and Stigma; CM: Establishing a Therapeutic Alliance; CM 2.2:
Engaging the CYP in Collaborative Assessment; CM 2.4: Establishing a Therapeutic Goal/Focus
with CYP; CM: Using Process Measures in Counselling.
 Therapeutic Skills
Sally Ingram and Maggie Robson

This chapter includes:

TREBLE DOI ED ETERS EE TIEIIE TET ESEEEES 6LIES SSE EFS NIELS ISISEISELE SEBEL IELTS SSE SES DETERS

e Generic therapeutic skills we utilise when working with children and young people rather than
describing the skills used in a specific modality
e A brief review of the research into the types of counselling and psychotherapy interventions
which appear to work the best
e A definition of therapeutic skills
e An outline of the BACP (2014) Competencies for Working with Children and Young People
e The argument that active listening is a generic therapeutic skill relevant across modalities
e Identification of the differences between working with children, young people and adults
e A discussion of the issue of working briefly

Introduction

This chapter focuses on the therapeutic skills we use when working with children
and young people. These skills are related both to our knowledge and also our beliefs
about what we feel is effective. These beliefs often rest upon our theoretical orienta-
tion. So, the first question we may need to ask is ‘what works best? This is addressed
in Chapter 16 of this handbook, “Evaluating Counselling. However, probably the most
184 The Handbook of Counselling Children & Young People

comprehensive overview of research into the efficacy of working with children and
young people is to be found in the recently published BACP scoping review on research
on counselling and psychotherapy with children and young people by McLaughlin
et al. (2013). The study examined evidence from meta-analyses, systematic reviews
from controlled trials, cohort studies, case studies, observational and exploratory stud-
ies, and ‘methodological papers that raise issues for future research in this field’ and so
gives an exceptional overview of research in this area.
The review builds on the previous scoping review by Harris and Pattison in 2004 and
asks the same question: Is counselling and psychotherapy effective for children and
young people? Three sub-questions were also explored:

1. Which types of counselling and psychotherapy interventions work?

2. For which presenting problems?
3. For whom?

In terms of techniques, CBT, psychodynamic, play therapy, humanistic therapies and

interpersonal psychotherapy were all found to be beneficial, with some approaches
seeming more beneficial than others with particular presenting problems.
Contained within the review is a report of a study by Bratton et al. (2005), who con-
ducted a meta-analysis into the efficacy of play therapy. They found that the results
were more positive for humanistic approaches and that inclusion of parents in play
therapy was associated with a positive outcome.
Part 1 of this handbook explores the therapeutic techniques of these different
theoretical approaches, whilst this chapter considers the knowledge and skills that
underpin all therapeutic encounters with children and young people, regardless of
orientation. It focuses, in part, on the therapeutic relationship and the skills utilised
to offer this. Rather than repeat the content of other chapters, the reader is advised
to read the relevant chapters to support understanding of this chapter. Chapter 1 is
relevant to the discussion of child development and attachment. Chapters 2 to 8 out-
line different theoretical approaches. In addition, the reader is also advised to read
Chapters 17 and 18 when considering law and policy and ethics and Chapter 16 when
curious about evaluation.
Lambert and Barley (2001) identified four factors that influence the outcome of
therapy: These were:

extra therapeutic factors, expectancy effects, specific therapy techniques, and common
factors. Common factors such as empathy, warmth, and the therapeutic relationship
have been shown to correlate more highly with client outcome than specialized treat-
ment interventions. (p. 357)

And they suggest that:

 Therapeutic Skills 185

decades of research indicate that the provision of therapy is an interpersonal process in

which a main curative component is the nature ofthe therapeutic relationship. (p. 357)

They argue that we need to tailor our relationship to our individual clients, in this case
children and young people, and improve our ability to relate to them.

What Are Therapeutic Skills?

Therapy is a process of relationship building and trust acquisition between the ther-
apist and the client. To facilitate this relationship counsellors need highly developed
therapeutic skills. Therapeutic skills are verbal and non-verbal ways of engaging
with clients in order to establish an emotional environment where a therapeutic
alliance can be created, maintained and safely terminated. This relationship is vital
if we are to assist clients in exploring how their life experiences have informed their
way of being and, if they choose, find new meanings and ways of relating to self,
others and life.
Corey (2001) reminds us that irrespective of one’s core therapeutic model, effective
counselling skills should be a carefully balanced blend of attention to our client's emo-
tions, thoughts and actions. In this way, we can enable our clients to reflect upon their
belief systems, experience the emotional depths of their internal and external struggles
and use these to aid new ways of being.
Rather than detail specific therapeutic skills, The British Association for Counselling
and Psychotherapy (BACP) have developed a set of competencies for therapists who
work with young people. These are available on their website (www.bacp.co.uk/).
These competencies have been developed as humanistic competencies but the core and
generic competencies, in our view, detail the general therapeutic skills and knowledge
relevant to all practitioners working both with children and young people regardless
of theoretical orientation. Some of the issues identified in these core competencies are
explored in detail within this handbook, reflecting the importance of these areas when
working therapeutically with children and young people.
Competencies identified by BACP (2014) include knowledge of child and family
development and transitions, and knowledge and understanding of mental health
issues. Knowledge of legal, professional and ethical frameworks is considered essen-
tial, including an ability to work with issues of confidentiality, consent and capacity.
BACP (ibid.) suggest that therapists need to be able to work across and within agen-
cies and respond to child protection issues. In addition, therapists need to be able to
engage and work with young people of a variety of ages, developmental levels and
backgrounds as well as parents and careers in a culturally competent manner. They
also need to have knowledge of psychopharmacology as it relates to young people.
186 The Handbook of Counselling Children & Young People

The generic competencies relate to knowledge of specific models of intervention and

practice, an ability to work with emotions, endings and service transitions, an ability
to work with groups and measurement instruments and to be able to use supervision
effectively. The ability to conduct a collaborative assessment and a risk assessment is
paramount. Crucially, BACP (2014) suggest the therapist needs to be able to foster
and maintain a relationship which builds a therapeutic alliance and understands the
client’s ‘world view. In our experience most proficient therapists, irrespective of their
modality, work to achieve this trusting relationship necessary for human change. Four
broad areas of the therapist’s intent within this relationship are described below:

Attention-Giving

This is where we actively demonstrate to clients through verbal responses, facial expres-
sions, eye contact and body posture that we are in a supportive, respectful, accepting
and authentic relationship with them. This builds respect and trust in the therapist-client
relationship.

Observing

This is where we observe the client’s verbal and physical expressions to enable us to more
fully understand our client’s experience, their relationship with the therapy process, their
life experiences and us. We believe that by noticing these, it leads to greater relational
depth (Mearns and Cooper, 2005). This relational depth allows the client to feel safe
enough to try out new ways of being, which can be a prelude to trying these outside of
the counselling relationship.

Listening

This is where we are actively listening (Rogers and Farson, 1987) to the content and emo-
tional experience of a client’s story, while listening out for indicators of how the client
defines their experience. At the same time, we are continuously communicating back
to the client that we have heard and understood their phenomenological perspective.
Active listening and affirming what we have heard imbues in the client a sense of being
understood and accepted.

Responding

This is where we are responding to a client's core communication. This involves reflect-
ing the content and feeling of the client's expressions while offering summaries that can
lead to further expression or exploration of how the client wishes to move forward from
current or historical experiences. This also gives the client the opportunity to modify the
internal view of their external experience, as they hear it reflected back to them. As we
discuss later in the chapter, the way we respond will need to be developmentally appro-
priate and may use other mediums of communication such as play.
 Therapeutic Skills 187

Although specific orientations, for example CBT, will have specific skill sets, the four
broad areas described above are often seen as the basis for therapeutic work with
children and young people. Taken together, these four areas can be described as dem-
onstrating the skill of active listening. Rogers and Farson (1987: 1) argue that:

People who have been listened to in this new and special way become more emotion-
ally mature, more open to their experiences, less defensive, more democratic, and less
authoritarian.

The fundamental premise is that these therapeutic skills span all client groups irrespec-
tive of age, gender, sexuality, cultural background and life experiences. What is key is
how we adapt attention-giving, observing, listening and responding to meet the unique
needs of the client before us. This is true for all client groups but never more so than
for those of us working with children and young people. For younger children, we may
adapt our active listening by communicating through play whereas older young people
may be more able to tolerate a more adult type of counselling experience.
Rogers and Farson (1987) describe the skills required for active listening. They
argue we need to really understand what the speaker is saying from their perspec-
tive and communicate that we have done this. When we listen, we have to listen for
‘total meaning’ — both the content of the communication and the feeling and/or atti-
tude underneath this. We need to ‘respond to feelings. The feelings can be much more
important than the content. Finally we must ‘note all cues. This means attending to
non-verbal as well as verbal communication and being aware of how something is
communicated, hesitantly or confidently for example. Again, we will adapt our skills
to the age and developmental level of our client and communicate through appropriate
mediums. For work with children, play is often the preferred way of working and this
is described in Chapter 7, ‘Play Therapy. Young people and adults can also find play
therapy very powerful but may feel it's babyish so age-appropriate ways of working
need to be employed. Younger adolescents may find it difficult to tolerate the focused
attention of the therapist so a third focus, often creative work, can be offered.
Using age-appropriate mediums will make the communication of active listening more
accessible. It is acceptable to be creative and not be fearful of inviting the client to consider
working in this way. Chapter 8, ‘Other Creative Approaches, offers some ideas and it may
also be useful to offer life simulation computer games as a powerful vehicle for the client
to express their world. Clients may choose to use mobile phone texting to share some of
the toughest experiences they are not able to verbalise. This may require a service phone
specifically for this purpose and some pretty fast texting skills on the counsellor’s part.
In addition to offering active listening skills which can be viewed as one of the under-
pinning skills of all interpersonal encounters, there is also a need for the specialist
skills that fit with different modalities and relationship needs of the client. Therapeutic
188 The Handbook of Counselling Children & Young People

skills when working with children and young people will be used to orperationalise
the philosophy of the particular modality. Person-centred counsellors will focus on
offering a relationship characterised by the core conditions (Rogers, 1951). Cognitive-
behavioural therapists will be looking to develop the therapeutic alliance in order to
help the client make connections between thought, emotions and behaviour (Beck,
1995). The psychoanalytic therapist will be aiming to develop a relationship in which
transference can occur and where unconscious material can be made available to the
conscious mind (Corey, 2001).

What Are the Differences between Working Therapeutically with

Adults, Children and Young People?

Although there are similarities between all therapeutic work, there are some important
differences. These include:

e Differing stages of development - emotional, moral, physical and cognitive: see Chapter
1 of this handbook, ‘Child Development and Attachment’
e Ethical and power issues: see Chapter 17 (‘Law and Policy’) and Chapter 18 (‘Ethics’) of this
handbook, and Daniels and Jenkins (2010)

Therefore, as has been suggested in the BACP (2014) Competencies for Working with
Young People, a knowledge of child and family development is essential, as well as a
knowledge of legal frameworks and an ability to work with issues to do with confiden-
tiality and capacity.
Therapeutic skills that enable us to work with adults are not necessarily suitable for
work with children and young people. In addition, those suitable for young people (ado-
lescents) are not necessarily suitable for working with children (primary school aged
children and younger). Those commissioning therapy for children and young people
share this understanding (Pattison et al., 2007). We need to appreciate what separates
children from young people and young people from adults, and how having a therapeu-
tically differentiated strategy can be the crucial element in providing safe yet effective
therapeutic outcomes. What should inform this strategy is an understanding of the
developmental stages young people grow through and which are described in Chapter 1.
Counsellors need to be aware of the significant impact these developmental stages
have on childhood understanding and communication and must be willing to adapt
their way of work to accommodate these variants (Churchill, 2011). Particular skills
in working with children and young people need to be developed. Part 1 of this
handbook, particularly Chapters 2 to 8, describe the theoretical base and skills
needed for a number of modalities for working in this field.
 Therapeutic Skills 189

The key stages of development include physical, emotional and cognitive function-
ing. These stages are rarely synchronised with each other and we would argue that the
chances of them being disharmonious is greater in young people who have suffered
early life trauma, This means that many of our clients may present as being under-
or overdeveloped physically, emotionally and/or psychologically in relation to their
expected stage of development. Client presentations of development will often not
parallel each other; a client could be physically overdeveloped and emotionally under-
developed. The case study is an example of this, the issues it may cause and the skills a
therapist may employ to manage this.
Culture may also affect the development of children and young people and how we
view their development. The age at which a child becomes a young person or an adult
varies from culture to culture and so we need to move away from adopting one static
theory of child and adolescent development and select one that can form a ‘baseline
starting point from which to modify and improve upon so that they maintain their
relevance in a rapidly changing multicultural society’ (Walker, 2005). He maintains:

We also need to reflect upon our own perceptions and beliefs concerning child devel-
opment and avoid rigid understandings. We need to ensure that we come from an
open, curious and culturally pliable position. (Walker, 2005: 15)

Another difference when working with children and young people is that of boundary
keeping, especially confidentiality. Children and young people are, in general, much
less autonomous than adults and have several groups of people interested in, concerned
for and responsible for their welfare (parents, relatives, carers, teachers, social workers,
dinner nannies for example). In our experience, to stick to the normal adult limits of
confidentiality can risk alienating the people responsible for the care of the child or
young person and may ultimately put them at risk. The carer may feel that the child or
young person is sharing ‘secrets’ that they feel threatened by or that you have an inti-
mate connection with your client that could jeopardises the relationship they have. In
order to keep this boundary sensitively, we need to develop communication skills that
will allow us tell the carers enough to keep them involved but not enough to violate the
child or young person’s privacy. Generalities such as “Things seem to be going well’ or
‘How are you feeling about the therapy?’ may suffice but thought needs to go into what
it is OK to say and what not. Supervision can help with these decisions and, if possible,
the client should also be involved. Sometimes the client wants you to act as a spokes-
person for them to their carers so a careful discussion of what is to be shared is vital.
The mechanics of therapy may also be different when working with children and
young people. Adults usually refer themselves for therapy but children and young people
may be referred by others, usually carers or teachers. If this is the case, both the client and
referrer need to understand what therapy is and the client needs to want to engage. It may
190 The Handbook of Counselling Children & Young People

be appropriate to offer a home visit to explain both the purpose and procedure of therapy
to both the client and the carer. In the case of a teacher referral, a programme of education
and information would ideally have been undertaken within the school.
In our experience, in private rather than school settings, we feel it may be better if a
carer could accompany a younger child and wait outside the therapy room as the child
may want to leave early. Also, having the carer involved in the practicalities of therapy
can help the therapist maintain a positive relationship with them.
As with adult clients, it is important to work and plan for the ending of therapy right
from the beginning (Robson, 2008) and, if possible, to include the client in planning
the final session. It is also helpful, in our view, to try and finish therapy at a time which
would resonate with a normal end, for example, the end of school term.

Relationship of Personal Qualities or Attributes to Therapeutic Skills

It has been suggested that the therapist needs particular qualities or attributes when work-
ing with children and young people (Geldard et al., 2013; West, 1996). These qualities or
attributes are conveyed through the use of therapeutic skills. They, and the associated
skills, will depend, to a certain extent, on the therapist’s theoretical orientation. West’s
(ibid.) description, although quite dated, is one that would be familiar to child-centred
play therapists. She suggests personal qualities should include the ability to

e Relate to, through and with feelings

e Understand and come to terms with what has happened in their own childhood, adoles-
cence and adulthood, including child-rearing and parenting issues
e Work within a child-centred framework
¢ Communicate with children
e Play
e Work alongside troubled children without being damaged by the children’s pain
e Actas an advocate for the children they have in play therapy. (p. 150)

Geldard et al. (2013), working from a more CBT stance, suggest four attributes for
therapists:

. Congruence
. In touch with own inner child
. Accepting
> . Emotionally detached. (p. 21)
BRWN

The final one, ‘emotionally detached, may be shocking for some therapists but they
do qualify this by saying that this ‘does not mean that the counsellor needs to be limp,
 Therapeutic Skills 191

lifeless and remote. On the contrary, the child does need to feel comfortable with the
counsellor’ (p. 23).
Whatever personal qualities or attributes we develop to further our work will be
communicated through the use of therapeutic skills. Each modality will dictate what
we are trying to convey to our clients and how we use our skills to do that. The use of
active listening skills can express empathy and attention giving and are qualities com-
monly valued by all approaches.

Working Briefly

Working briefly with children and young people will not necessarily change the skill
set employed by the therapist but can put pressure on the therapist to ‘solve’ the prob-
lem rather than concentrating on building a strong relationship with the client. As has
been suggested earlier, clients, particularly younger children, can find it helpful to end
therapy where a break in their routine would occur naturally, for example the end of a
school term. Brief or time-limited therapy may not allow this to happen.

=
Case Study Andrew
This case study demonstrates work with a client whose physical development had overtaken his
cognitive and emotional development and the skills the therapist used to help her client explore the
meaning of his experiences.
Andrew was 14 when he was referred to Liz, his school counsellor. He’d been at his new school only
five months after his mother had moved to the area seeking a fresh start after the end of another
violent relationship. Andrew had two younger female siblings and none of them shared the same
father. Andrew was not in contact with his father but his sisters’ fathers kept in sporadic contact.
Overall their life had been fairly nomadic since Andrew was about two years old.
Prior to the referral, at least three teachers had reported that Andrew's behaviour was becoming
more and more disruptive in class and one teacher had asked that Andrew be excluded permanently
from his class, after Andrew had ‘faced him off in front of other pupils’
Other staff and pupils had reported that they found it hard to warm to Andrew and that he
had done little to integrate himself into his new school community. Andrew's year head accom-
panied him to his first counselling session to, as the year head put it, ‘make sure he bothered to
turn up’

(Continued)
== BE,
 192 The Handbook of Counselling Children & Young People

te(Continued)

The first thing that struck Liz about Andrew was his physical presence. Andrew was incredibly
tall and broad for his age and could easily have passed for a baby-faced adult man. Andrew's pos-
ture, attitude and general manner was one that seemed to demonstrate nonchalance bordering
on arrogance. Liz opened the early stages of her work with Andrew by congruently reflecting the
path by which he had arrived at counselling. Liz explained it felt their coming together had been
coerced. She disclosed her own dissatisfaction about this, and explained that one of the funda-
mental tenets of counselling was that it had to be a voluntary process that both parties wished
to freely engage in.
Andrew said he had no problem attending counselling but he did not know why others thought
he would benefit from it. Referring to his teachers, he stated that the only thing that would be gained
by counselling was that others would be pleased because he would be ‘out of the way as usual!
Despite his physical stature, Liz noticed that when Andrew said this, he seemed small and diminu-
tive; his posture was hunched and almost foetal like. Liz reflected back to Andrew that he didn’t seem
pleased by the idea that people wanted him out of the way and asked if his teachers were the only
people that seemed to enjoy his absence.
Andrew then gave an outline of his life, explaining that it was only men who wanted him out of
the way — male teachers, mum’s boyfriends and male peers. Most of Andrew's early years had been
deeply fractured; he could report no consistent male role model, just a series of men who drifted in
and rather violently out of his family’s life. Despite his apparent physical maturity, it was clear that
Andrew carried a rather young and naive sense of blame for the patterns in his mother’s relation-
ships. ‘They get sick of me you see’; ‘They don’t mind my little sisters’;‘Itis only my dad doesn’t keep
in touch’
Liz invited Andrew to explore how he felt about ‘being out of the way’and he explained that some-
times it was for the better. For many years there had been multiple violent incidents that he had
heard and observed. These culminated in his mother being so badly beaten that she had a punctured
lung and was unconscious. Andrew was deeply disturbed by this incident, explaining he regularly
‘saw’ it when he closed his eyes and he ‘daydreamed’ about it. With the help of supervision Liz began
to realise that Andrew was describing early signs of post-traumatic stress and that his daydreaming
appeared to be an indicator of intrusive daytime imagery. Liz’s supervisor encouraged her to give
Andrew more space to explore his daydreams.
Andrew explained daydreaming was why he had been excluded from class. He was being seen
as uncooperative and had been described as blatantly ignoring classroom instructions. In fact what
Andrew said was happening was that he was ‘zoning out’ in thinking about what had happened to
his mum.
In his own language, prompted by accurate reflections from his therapist, Andrew began to articu-
late the internal conflict he experienced between physically appearing as an adult while internally
feeling young and fearful. ‘I’m built like a brick shit house’; ‘I should be able to protect my mom. I’m
big enough but I’m a pussy’

S 24)
 Therapeutic Skills 193

ee

Andrew's stature was a real hindrance to him as he was regularly perceived as being an adult. This
led others to place unrealistic expectations upon him in terms of his behaviour, attitude and emo-
tional resilience. Andrew had internalised many of these expectations, especially when it came to
protecting his mother. His inability to live up to these internalised standards ultimately led Andrew
to feel a great sense of shame and physical and emotional impotence. Andrew's arrogance, non-
chalance, and burgeoning aggression, seemed to be his way of covering what he felt sure others
could see in him.
Liz recognised initially she had also been a little blinded by Andrew's stature and that she had the
challenge of building a relationship with a vulnerable young man whose sense of self was incredibly
fragile. The work began to focus on what attributes Andrew wanted people to see. Andrew said he
wanted people to see his sporting and artistic skill, although he wrestled with the latter as this was‘a
wussie’s game’ The remainder of Liz and Andrew's work focused on attending to the common ques-
tion that is present for many adolescent clients (Horne, 1999):‘Who will | be?’
Over the following weeks Liz and Andrew returned to Andrew's image of who he might be and
explored which elements of this could be facilitated through change within his life and which ele-
ments needed to be accepted as currently unachievable. During one particularly difficult session,
Andrew became distressed when he realised that he could never have protected his mum from
domestic abuse as for many years he’d been physically unable to because of his youth and small stat-
ure. His recent physical development had left him with a feeling that he should have done something
to protect his family. This led Andrew to look at the limits and scope of his own personal responsibil-
ity. Andrew found this frustrating but was willing to accept on a cognitive level that he had not had
the capacity to protect his family and because of this, he could not be responsible. Throughout the
counselling encounter Liz used active listening to try and enter Andrew's world and congruently
worked with the dissonance between his developmental levels.

Summary

In this chapter we have:

e Argued that we need different therapeutic skills and knowledge when working with children
and young people
e Detailed the competencies required and highlighted the importance of the skill of active
listening.
e Considered the impact of the developmental stage of the client on the therapy
e Explored the differences in working therapeutically with children, young people and adults
e Provided a case study to demonstrate the dissonance that can occur between different ele-
ments of development and how the therapist uses her therapeutic skillstoattend to the whole
client experience
RRR SESE EDDIE SYED DES SSE LETTE IIT SELES ELISELI LIEDELLE LETIS BEE LEI LEE ATA
194 The Handbook of Counselling Children & Young People

Reflective Questions

e Can you think of a child or young person where their physical, emotional, cognitive or
behaviour development is not synchronised? Does this cause issues?
e Are there any special attributes or qualities that you feel a therapist working with children
and young people should have? If so, what are they and why?
e Why might it be important to communicate to carers of the child or young person some-
thing of what is happening in your therapy sessions?
e What do you think are the most important skills for a therapist when working with chil-
dren and young people?

*% ?

Learning Activities

e Think about your school days and about your teachers. Think of one good teacher and
one bad teacher. What were their qualities/behaviours/attributes that made them good
teachers? What were their qualities/behaviours/attributes that made them bad teach-
ers? Can you list them? Think about your ‘good’ list. Does it connect in any way to the
suggestions made by Rogers and Farson (1987) about how to listen actively?
e Write a list for yourself of the different skills required to work with children and young
people. If you do not already have these skills, where could you learn them? Do a search
for training providers.
e West (1996) suggests that in order to work with children and young people we need to
‘understand and come to terms with what has happened in [our]/their own childhood,
adolescence and adulthood, including child-rearing and parenting issues. How could
you do this?
e West (ibid.) also suggests that we ‘work alongside troubled children without being
damaged by the children’s pain’: What sort of strategies can we put in place for ourselves
to help us manage this?
é i] ®

Further Reading

Baruch, G. (2001) Community-Based Psychotherapy with Young People: Evidence and Innovation in
Practice. Philadelphia: Taylor and Francis.
Bowman, R.P. and Bowman, S.C. (1998) Individual Counselling Activities for Children. Chapin, SC:
Youth Light.
 Therapeutic Skills 195

Harris, B. and Pattison, S. (2004) Research on Counselling Children and Young People: A Systematic
Scoping Review. Rugby: BACP.
Lines, D. (2002) Brief Counselling in Schools: Working with Young People from 11 to 18. Thousand
Oaks, CA: SAGE.
Luxmoore, N. (2000) Listening to Young People in School, Youth Work and Counselling. Philadelphia,
PA: Taylor and Francis Group.
McLaughlin, C., Holliday, C., Clarke, B. and Llie, S. (2013) Research on Counselling and Psychotherapy
with Children and Young People: A Systematic Scoping Review of Evidence for its Effectiveness from
2003-2011. Rugby: BACP.
Mapes, K. (2000) Stop! Think! Choose! Building Emotional Intelligence in Young People. Tucson, AZ:
Zephyr Press.
Ponterotto, J., Casas, M.J., Suzuki, L.A., Alexander, C.M. (2001) Handbook of Multicultural Counselling.
2nd edn. Thousand Oaks, CA: SAGE.
Schaefer, C. (ed.) (2003) Foundations of Play Therapy. Hoboken, NJ: John Wiley & Sons.
Simpson, A.R. (2001) Raising Teens: A Synthesis of Research and a Foundation for Action. Boston:
Center for Health Communication, Harvard School of Public Health.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially Modules CMD 02: Participation
and Empowerment; CMD 03: Legal and Professional Issues; CMD 04: Cultural Competence;
CMD 05: Initiating Counselling; CMD 07: Relational Skills; CMD 08: Therapeutic Skills; CMD 10:
Concluding Counselling.
Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT): www.cypi-
apt.org.
Griffiths, G. (2013) Helpful and Unhelpful Factors in School Based Counselling: Client’s Perspective.
Counselling MindEd Scoping Report. Available at: http://counsellingminded.com/wp-con
tent/uploads/2013/12/griffiths_MindEd_report.pdf.
 Supervision
Penny Leake and Ann Beynon

This chapter includes:

SS
SSSSSSSVo°:;:..coxX—_
e Ageneral introduction to the role and definition of supervision
e Apresentation of a working model of practice
e Ahistory and background to this professional development
e A theoretical underpinning of the supervisory relationship
e Acase study
e Research
e Questions and activities for reference and discussion
e Further reading
e Summary

Introduction

In this chapter we will look at the supervision of therapeutic work with children and young
people, examining its history, theory and practice. We shall look at a working definition
of such a supervisory relationship and examine how the supervisor has to take account
of how work with children and adolescents is different from work with adults. We will
explore the issues of creativity and of power, and suggest activities and reflective ques-
tions for both practitioner and supervisor. The chapter also contains a case study, some
suggested reading, and thoughts about what research exists and what more is needed.
 Supervision 197

Therapeutic work with children and young people can be undertaken in many set-
tings, and practitioners may espouse a variety of models of working. The latter may
largely be influenced by the age/developmental stage of the child or young person. The
supervisor chosen by the practitioner (if choice is possible) will need to be comfortable
with the variety of needs the supervisees will therefore bring, as well as having a good
understanding of the ways in which supervision of work with children and adolescents
is different from supervision of work with adults.
There have been many working definitions of the triple function that supervi-
sion serves in work with adults, and we have chosen Houston's (1995) description of
‘policeman, plumber and poet’ to look at in the context of child and adolescent work.
Houstons use of metaphor in her definition seems very appropriate when we think
about work with children, their communication being so rooted in symbolism. This
creative aspect of the work, so frequent in the therapy itself, can get forgotten about as
a tool in the supervisory process.

Policeman

The ‘policeman’ metaphor reminds us that the ultimate function of supervision is to ben-
efit and protect the child client, even though the practitioner is likely to experience it as
a benefit to themselves. In their extensive writing on supervision of adult work, Proctor
and Inskipp conclude that it is not possible to have an exact parallel of Rogers’ core condi-
tions in the supervisory relationship, because the need for rigour is not compatible with a
completely non-judgemental attitude. A clinical supervisor, just like a line manager, has a
vicarious liability for the standard of work being done. The version of the core conditions
which Proctor and Inskipp therefore describe is one of empathy, respect and genuineness.
The kinds of duties which the ‘policeman’ may have to fulfil are best discussed
between the supervisor and the practitioner at the outset and set out in a written con-
tract in order to model good boundary-keeping and to avoid any later discomforts.
Examples of items in the contract would be the extents and limits of confidentiality,
the keeping of records and serious concerns about the standard of work. One of the
important ways in which supervision of child and adolescent work is different from
supervision of adult work is the need to keep in mind the legal framework that sur-
rounds practice. Sometimes the practitioner can lose sight of this in the midst of the
therapeutic relationship. Legal issues (such as safeguarding, parental responsibility or
the child’s competence to make decisions) can lead to very difficult dilemmas for the
practitioner around confidentiality. It is good to have reference in the supervision con-
tract to what kind of issue can stay within supervision and what may need to go outside.
If the practitioner works for an agency there will be times when agency policy must be
followed quickly and the line manager consulted rather than the clinical supervisor.
198 The Handbook of Counselling Children & Young People

The level of experience of the supervise is likely to affect how frequently the ‘policeman’
function comes to the fore, and this can also affect the character of the ‘plumber’ aspect.

Plumber

Here Houston is referring to looking at the nuts and bolts of the day-to-day work, the
discussion of individual sessions, the progression of the series, the need for additional
training, etc. If the supervisee is on a qualification course, or if s/he feels the need
for some minute attention to a session, this may take the form of looking at a video
recording together. The supervisor might give straightforward advice in a case like this.
Supervisors of work with children and adolescents need to have experience in the field
themselves. Sometimes drawing on this to make practical suggestions may be helpful,
but too much may interfere with the collegial exploration which is likely to be the most
successful. Houston believes that her best work as a supervisor is when the therapist
supervises herself in front of her.
This ‘plumber’ work may well be done cognitively, but there will be times when
the supervisee brings feelings of ‘stuckness’ which s/he finds elusive and difficult to
describe. This is an ideal opportunity for the supervisor to invite the supervisee to use
creative ways of exploring, such as by using stones, sand, art, play therapy figures, etc.
In so doing, the supervisee’s emotions about the work are likely to come to the fore,
and parallel processes may emerge. This is where the third function of supervision, the
‘poet’ work, is crucial.

Poet

The ‘poet’ in the supervisor listens out for themes and patterns, but above all listens to
the music under the words, which gives clues to the supervisee’s feelings about the child
and those in the child’s system. Sometimes the supervisee knows all too well how she
feels, and can say so given the right atmosphere. Our feelings when working with chil-
dren can go beyond counter-transference, as we are working with an actual unhappy
child in real time, and this may bring out natural protective instincts which can lead to
rescuing and unhelpful mothering behaviours. The practitioner needs to stay with the
child's pain, and this is very difficult to do. She needs to be able to bring these feelings
to supervision in order to lessen them, both for her own sake and for that of the child.
When working with adolescents, more negative feelings may be triggered, if hostility
and attachment difficulties are being directed towards the counsellor. Practitioners may
find working with self-harm and disordered eating particularly anxiety-provoking.
 Supervision 199

Other people in the child’s system may cause the practitioner to feel professionally
isolated, angry or inadequate. It is the feelings of inadequacy and other vulnerabilities
that cause practitioners to want external clinical supervision rather than any that may
be contracted within their agency. This is the effect of the power issues inherent in any
supervisory relationship, irrespective of how good the agency’s supervisor (or, indeed,
line manager) may be. The reality may be that choice may not be possible, as agencies
may wish to have a tight accountability for the work, although a clear three-way specimen
contract from a potential clinical supervisor may help here.
Sometimes, however, a carefully boundaried in-house supervision programme can be
useful — such as when both group co-facilitators can be supervised together, or as a way
of getting insight into the tricky systemic issues that are so central to work in this field.

History and Background

In the 1960s and 1970s, the ‘birthing period’ of counselling for children and young
people in education, approaches to counselling practice learnt much from the devel-
oping fields of child psychiatry and social work, not least in terms of the integrated
models of management supervision in delivering effective practice. In Anne Jones’
visionary and practical account of her work as a counsellor in Mayfield Comprehensive
School in London, she recognises the integral purpose of supervision.

For a counsellor to deny the emotional repercussions a counselling interview may

cause within him may block any growth and development in his work and possibly
indirectly to his client. To face and accept his limitations and to make the best of them,
the counsellor needs help — systematic, structured and specific help. (1970: 170)

She talks of finding ‘our own unofficial channels of support and supervision to meet
this need, a practical exercise which many counsellors, nationally, were engaged in dur-
ing this period. Individual and group supervision contracts were explored with the
psychological, psychiatric, welfare and education services, building the understanding
and acceptance that ‘to appoint supervisory personnel specifically for counsellors is not
an extravagance but an essential?
During these early years supervision, or tutorial sessions, had become an integral
part of generic counselling training programmes and finally became recognised as a
requirement for professional accreditation by the British Association for Counselling
and Psychotherapy (BACP) and other professional bodies. Thus the need for specific
training for counselling supervisors as a distinct professional role and function became
increasingly apparent and a number of training courses were developed in the 1980s
and 1990s based on a variety of theoretical models.
200 The Handbook of Counselling Children & Young People

The BACP/NHS MindEd online training for counselling with children and young people
coming on-stream in 2014 has designated modules on the supervisory relationship.
In recent years many counsellors have initiated peer mentoring services in their
schools, working in partnership with other members of staff. Provision for integrated
supervision for both mentors and staff is crucial to sustained service development.
Helen Cowie and Patti Wallace (2000) go as far as to say: ‘If there is really not enough
time to supervise peer supporters regularly, perhaps it is not the best time to set up a
peer support service.
They describe the function of supervision in this context as follows:

it can be a forum for monitoring the effectiveness of the service, a forum in which ideas
for further training can be generated and, if done in a group, it can help to develop
cohesiveness within the group of peer supporters. (Cowie and Wallace, 2000: 134)

Thus with an infrastructure of consistent and creative management and supervision

the value of these outreach services alongside a counselling provision can actively
influence an ethos of mutual awareness and openness in a school community.

Theoretical Underpinning

Supervision of therapeutic work with children and young people has to take account of
how this work is different from that with adults.

Systemic Thinking

A fundamental difference is that children, in particular, and young people, to a large

extent, do not have personal autonomy. They are part of a system that includes parents,
foster-carers, culture, school and possibly other agencies. If a parent is hostile to the
idea of therapy for a younger child, they have the power to forbid it, sabotage it, with-
hold it as a punishment or turn it into a scapegoating process. A Fraser-competent
young person may be able to have counselling in a school setting without their parents’
knowledge, but here the system of the school could itself cause tensions. The supervisee
can find that many people besides the child are taking up her headspace. She may need
the supervisor's help to sort out which of these extra players need to be centre stage and
which can be in the wings.
She may also need a safe place to vent frustrations about parts of the system, and a
containing supervisor can help with any accompanying issues of splitting and activation
 Supervision 201

of Karpman’s drama triangle (see below). The supervisor may be able to spot if the agency
is mirroring the issues of the client group they work with, if practitioners are mirror-
ing family dynamics, or if a parallel process is emerging in the supervisory relationship.
Anything that can be done to get the system on board is likely to make the therapy more
effective.
Sometimes family therapy is needed rather than individual, and this need may
become clear through discussion in supervision. Sometimes the supervisor has to sup-
port the therapist in facing the fact that his or her work can only be damage limitation,
and that a good therapeutic relationship now may enable the child to seek therapy
again when an autonomous adult.
Information-sharing within the system is always a tricky business. The looked-after
system may expect frequent sharing. If a practitioner was originally trained in adult
counselling, the principle of tight confidentiality may still be firmly rooted in them,
and the supervisor can help with the discomfort that information-sharing may bring.
It may be helpful to look during the supervision session at the written ethical guid-
ance that is produced by professional bodies such as BACP and BAPT, and to think
through together how far and in what ways ethical principles such as non-maleficence,
autonomy and fidelity can apply to work with children. Age and developmental issues
will be crucial here.

Developmental Issues

Many of the complex threads which distinguish child and adolescent work from adult
work come together in the subject of age and stage of development. Both practitioner
and supervisor need to have a good understanding of child development, especially
emotional development. A framework such as that of Erikson (1965) can be helpful,
combined with an understanding of how trauma and disability can skew these stages.
A young person who is considered Fraser-competent can reasonably expect that his or
her issues will be kept confidential, with the usual exceptions of harm to self or others.
However, degrees of harm may cause grey areas that need to be explored in supervision.
The thought of the law, parental anger, cultural opposition and possible court appearance
can make the practitioner feel very precarious. Consultation with the Children’s Legal
Centre may be helpful here. On the other hand, a therapist trained in adult work may
need reminding that promises of confidentiality to a young child can have resonance of,
for example, ‘our special secret, which can cause confusion rather than healing.
Embedded in person-centred work is Rogers’ concept of ‘the wisdom of the client:
Practitioner and supervisor may wish to discuss how far this concept can apply to work
with children and young people. They may well have perfect wisdom over the pacing
202 The Handbook of Counselling Children & Young People

of their sessions and the methods of communication they will use. There will, however,
be some decisions, depending on age and understanding, that they cannot make and,
sometimes, should not be asked to make. A practitioner may have to think about who
should be present at any feedback meetings with parents or carers. Whilst a young
person may well want to be present, it would be counterproductive for a young child to
hear their unconscious symbolic play being decoded for the benefit of adults.
The supervisee, too, has stages of development, and the supervisory relationship may
need to adapt accordingly to advancements and to any regressions caused by profes-
sional or personal insecurity.

Attachment Issues

The children and young people whom therapists see are likely to have difficulties
with attachment. This may be because early attachment was skewed through abuse or
neglect or because it was disrupted through bereavement or separation. These attach-
ment patterns are likely to be acted out in the therapy room, and may cause a variety of
discomforts for the practitioner.
The early stages of the work are likely to echo the anxiety, hostility, avoidance or
ambivalence of a child’s insecure attachments. Ambivalent attachment can manifest
itself in anxiety to please. The child may need a period of being securely attached to
the practitioner before being able to move on, and judging when this time has come
can be difficult. The subjects of dependency and endings are likely to be brought to
supervision, and the supervisee’s own feelings may well need to be disentangled from
the needs of the child, especially if the attachment has started to become mutual. The
supervisor can help the practitioner to feel that the child is getting a good, predictable
ending rather than the many unpredictable ones they have had in the past.
The attachment issues of adolescents are additionally complex because of their need
to begin attaching to peers and push away parent figures. Moving from individual work
to group work is therefore ideal here. If the supervisee is facilitating a group, there are
many people, issues and powerful feelings that will be present in the supervision room.
The use of creative methods of supervision, such as with stones or Russian dolls, can
help to make this feel more clear and manageable.

The Supervisee’s Feelings

It is difficult for a counsellor to stay with the pain of adults, but staying with the pain
of children is especially difficult. There is a great temptation to minimize, distract and
 Supervision 203

rescue. Landreth suggests that anyone who wants to be a play therapist should ask
themselves several searching questions, such as how much they need to be needed and
whether they feel guilt about limit-setting.
Supervisees can bring complex and overwhelming feelings to supervision. Issues of
counter-transference may be at work, or real-time sympathy or despair for a vulner-
able child. A child can silently call to the supervisee’s inner child, or evoke feelings
about children in her family, or lack of them. Through projective identification, the
therapist may get an unbearable feeling of what it is like to be this child. If the feeling
is one of guilt and inadequacy, the supervisor may be able to point out the process
that is happening, and so normalize what the therapist may be feeling about her work,
disentangling what is hers and what is the child’s. The supervisor, too, may experience
strong feelings, and generally these can be brought into the room so that an exploration
of parallel processes can help with the clarification.
Counsellors and therapists are constantly having to swallow down children’s pain, and
this needs to be assuaged in supervision and in other replenishing activities. If it is not, it
can become toxic to the practitioner, or lead to defences which protect the therapist but
can give a subtle message to the child that there are some no-go areas in therapy.
We know from neuroscience that a practitioner can be simultaneously flooded with
the same unhealthy cortisol as is the child they are listening to. Equally, the child can
pick up the opioids generated by calmness and containment. The supervisee needs a
containing supervisor to increase her own opioids and diminish cortisol. So, too, the
supervisor has to hear pain and contain splitting, and he or she needs to keep up their
own regular supervision for identical reasons.
The supervisor's overview of many cases can help him or her to remember that chil-
dren heal more quickly than adults given the right circumstances, and this can help to
keep the therapist's optimism alive. Sometimes, however, the supervisor may sense that
the supervisee’s usual resilience is being chipped away by too much pain, and the subject
of time out and/or burn-out may have to be raised, with the help of a diagnostic ques-
tionnaire if necessary. Sometimes there are so many personal issues impacting on the
work that it becomes clear that the supervisee may need personal therapy in addition to
clinical supervision. Here the supervisor can model good boundaries, signposting the
supervisee elsewhere for this and not letting supervision become a kind of counselling.

Legal Issues

This has been referred to under ‘policeman in an earlier section of this chapter. It is the
practitioner's responsibility to be very familiar with all issues of safeguarding children,
Fraser-competence, the basics of current Children Acts, the latest assessment frame-
work, and his or her own agency’s procedures. However, the supervisor also needs
204 The Handbook of Counselling Children & Young People

knowledge on these matters. There needs, for example, to be a clear understanding

about when a child’s wish for confidentiality has to be overruled, whilst at the same
time minimizing any harm from this. Acting on disclosures of abuse can be distressing
for both child and practitioner, and there will also be a need for the therapist to seek
legal advice on how soon play therapy or counselling can be resumed after legal pro-
ceedings have been begun. With both children and adolescents there is a greater danger
of the practitioner being accused of ‘coaching’ the child in their evidence than there is
in equivalent adult work. The supervisor can model the careful record-keeping that is
always necessary in child therapy, and there can be discussion on the complexities of
this. Any court appearance is likely to be stressful for the practitioner, and he or she will
need support from both supervisor and line manager.

Symbolism and Creativity

Older children and adolescents may communicate in a counselling relationship like adults
do, using words and perhaps art. They may also be disconcertingly silent. For younger
children, however, it is not natural to them to talk about what troubles them. The play
therapist and supervisor are likely to spend much time discussing hypotheses about sym-
bolic play. If this is done mutually, without the supervisor doing all the interpretation,
it can be fascinating and rewarding for both, even if the material is sad. Sometimes the
therapist will have to continue explaining to impatient people in the system that the child
is not ‘just playing; and this can make her feel frustrated and professionally isolated.
The supervisor and therapist together can look for the signs that the urgent symbolic
play is diminishing, and ordinary playfulness is increasing - a sign that the work is
nearing its end.
Ideally the supervisor will offer creative methods in supervision so that the uncon-
scious and the right brain are as active for the therapist as they are for the child.

Power Issues

The supervisor will have been congruent in the contract about the power issues inher-
ent in the supervisory relationship. A clause about regular review of both the contract
and the relationship may help to avoid some of the dangers of long-term supervisory
relationships.
Karpmans drama triangle (1968) of victim, rescuer and persecutor can be activated
especially easily in therapy with children and young people because children have little
power and we frequently see them as victims. It would be easy for this dynamic to be mir-
rored in the supervision process, and supervisors need to be on their guard against acting
 Supervision 205

on such feelings, especially that of wanting to rescue. That is not to say that supervisees do
not need to hear their good work regularly praised to keep up their enjoyment of what they
do. A containing adult-to-adult atmosphere will make drama triangle dynamics less likely.
The power/powerlessness issues of difference and diversity are important here.
Amongst the many conscious and unconscious triads which feature in supervision,
there can be a sub-system of two and an odd one out. Already the practitioner and
supervisor are adult, and the client is not. If in addition the supervisee and supervisor
are, for example, white and the child is black, it is possible for unconscious filtering and
collusion to occur. Equally, there could be times when child and therapist are in a sub-
system which is causing boundary difficulties, and the objectivity of a supervisor from
a different grouping might be helpful.

Case Study Pippa

Pippa had worked for three years in a CAMHS Tier I! community team, which mainly took referrals
from social workers. She had been trained in adult counselling, but had had in-house training in
therapeutic work with children and adolescents.
Pippa was allocated a new case, where even the referral details made her feel overwhelmed. Adam
was a nine-year-old boy, a looked-after child living with his grandparents. By the time he was six, he had
been physically, emotionally and sexually abused and had seen his mother die of a cerebral haemor-
rhage as she was cooking the tea in front of him. For three years he had been quiet anc no-one had
thought he needed therapy, but now he was being oppositional and destructive at home, and his Nana
was not sure that she could continue to look after him if his behaviour did not improve
Pippa took her feelings of being overwhelmed to supervision even before her first session. She
had never known a child suffer so much, and even his system, which included complex reconstituted
families, was more than she could grasp. Jane, her supervisor, suggested using Russian dolls to clarify
this, and this externalizing and miniaturizing helped Pippa to feel less submerged.
Pippa had to use a room mainly used for adult work. Adam's Nana had said he liked art, and when
preparing the room Pippa had put out very many large tubes of poster paint. She realised later in supervi-
sion that this was her‘rescuer’atwork. Adam had squirted paint wildly, which had stained the carpet, and
made much mess with sand and water. He had also banged loudly on the walls. Pippa found herself wor-
rying about what other people would say, and was powerfully reminded of when her own toddler made a
mess in someone else's house. She had coped with boundary-testing before, but realised there was rightly
no mention of mess or noise in the ground rules which she had outlined to him earlier. He was very excited
when his Nana came to collect him, and Nana looked worried. She wanted to talk to Pippa in front of him,
but Pippa gently put her off. Pippa went home worrying that she might have done more harm than good
in letting him be so wild.

ooo
 206 The Handbook of Counselling Children & Young People

(Continued)

She had lots of unease to share at her next supervision. Jane made the practical suggestion ofasking
if Pippa could change the therapy day to one when no-one was using the room next door. This was sim-
ple but extremely effective ‘plumber’ work. Jane also contained Pippa’s feelings in a calm and respectful
way. They reflected together on what mess might mean to Adam, and Jane suggested slightly re-stat-
ing the ground rules to ‘no damage that can’t be put right’ This later proved to be a deep insight on
Jane's part.
Pippa stayed with the process with more confidence over the next month. Adam’s mess began to
focus itself into a game of anaughty, messy baby. He sucked on a baby’s bottle, and wrenched Pippa’s
heart by crawling round saying someone had taken his bottle away and he couldn't find it. She did,
however, feel this was progress — until the phone calls started coming in.
Nana had been worried by Adam telling her he was drinking from a feeding bottle, and she had
shared her fears of regression with a liaison teacher. The teacher had rung Pippa and said, ‘He needs
to be made to talk’ and had advised immediate referral to one of Pippa’s colleagues. After a moment
of indignation, Pippa went into self-doubt, and suddenly felt inexperienced. Luckily, her supervision
was the next day. Jane was able to help her to see that the good therapeutic relationship meant she
was the right person to do the work, but that she had not taken enough account of systemic issues.
Pippa quickly arranged a programme of regular feedback meetings, which Adam had no objection
to, some just with Nana and some with the professional system as well. Pippa came to realise how
deep Nana’s anxiety went, and how she also needed signposting to counselling for her own grief.
After that, the system was fully supportive of the therapy, and enhanced it by making adjustments
in the outside world.
Pippa had to contain Adam's splitting of his vulnerability and his anger in many dizzying role
reversing dramas, which she took for her own containment to supervision. Just as she was beginning
to gain more confidence, she heard from Nana that Adam had recently exposed himself at a family
party and put his head up a girl's skirt.
Pippa was used to working with victim issues, but not with sexually harmful behaviour. She
needed all Jane's ‘policeman, plumber, poet’ functions, together with line management involve-
ment. Pippa’s growing attachment to Adam tempted her to minimize what had happened, but
Jane was clear that the behaviour had to be addressed at once and mainly cognitively, both sup-
portive and challenging. She helped Pippa to see that it was important neither to under-react nor
over-react to what had happened, and to use an age-appropriate assessment process, including
other members of the system, to see if this was an ‘amber light’ or a ‘red light’ situation. Because
they concluded it was the former, it was felt Pippa could do the work herself with Jane’s supervision
and some further reading
Pippa was enabled to do this, and Adam showed no more sexually harmful behaviour. He resumed
his symbolic play, acting a kick-boxing baby who integrated his earlier splitting. He invited Pippa to
be ‘the Mam‘ Over the weeks, he directed Pippa in dramas in which the mother was angry with the
 Supervision 207

messy baby, and their mutual anger and rejection escalated to the point where the mother
a)
died —
died whilst cooking the tea. Pippa knew the theory of children’s magical thinking about their
own
responsibility, but she had never felt it in her stomach until that day. She needed to discharge her
pain in supervision, and also to talk about the way forward, whether it was right to stay indefinitely
with this bleak pain or intervene to move it on in some way. Jane pointed her in the direction of
literature which suggested that repeated post-traumatic play does need to be interrupted.
At Adam's next repetition of this scene, Pippa was able to use what she had learnt, together with
her own intuition, to make the dying mother say words of reconciliation and reassurance that he was
not to blame. After that, Adam's play showed themes of forgiveness, hope and growing self-esteem,
and ordinary interactive games began to appear
Adam was by now halfway through the third reviewed series of six sessions. Pippa knew that the
journey they had been through together made her reluctant to let him go, even though she knew
the work was done, and that he was behaving well at home and starting to transfer his attachment
to his Nana. Jane reminded her that it is the therapist’s job to make herself unnecessary. Pippa took
comfort from this and kept it as a mantra. She was able to do a good ending, and she and Jane
looked back together with satisfaction on what had eventually been achieved from such a daunting
beginning.

. ; oe
Research

From our experience of researching the nature of therapeutic supervision, we can

verify the scarcity of research undertaken to evidence the value and nature of the
role and function of supervision, particularly for counsellors working with children
and young people. In this chapter we have summarised the theory and history of the
integral place developed and held by supervision within the delivery of good and safe
counselling practice. Recent evaluations of school counselling, such as the Counselling
in Schools Project in Scotland (Cooper, 2004) and the Welsh School-based Counselling
Strategy 2011 (Hill et al., 2011), provide encouraging evidence of the effectiveness of
counselling in schools, based on detailed qualitative and quantitative evidence but,
and maybe appropriately for their focus, with little or no reference to the need and
place of the supervisory relationship in the service delivery. Similarly in “Research
on Counselling Children and Young People: A Comprehensive Systematic Scoping
Review, undertaken by Belinda Harris and Sue Pattison in 2004, the function and
training requirements for supervision is absent.
In the BACP’s supervisors’ workshop devised for circulation by Francesca Inskipp and
Brigid Proctor in response to the need to introduce the re-framed Ethical Framework
 208 The Handbook of Counselling Children & Young People

for Good Practice in Counselling and Psychotherapy in 2003, key statements for con-
sideration under the heading ‘Supervising and Managing’ were as follows:

e Practitioners (supervisors) are responsible for clarifying who holds responsibility for the
work with the client.
e General obligation for all supervisors to receive supervision/consultative support inde-
pendently of managerial relationships.
e Supervisors’ responsibility to maintain and enhance good practice by practitioners, protect
clients from poor practice ... acquire attitudes, skills and knowledge required by their role.

The above statements might well form the focus for much needed research projects; to
justify their importance through practice-based evidence, indeed supervisors them-
selves are in a prime position to take up this initiative. The recent BACP research
initiatives SuPReNet, Supervision Practitioner Research Network, and SCoPReNet,
School-based Counselling Practice Research Network, which provide support to prac-
titioners to undertake practice research projects, are a welcome resource to build this
research base into the future.
Without comprehensive research for this dimension of counselling practice,
commissioners of counselling services can be forgiven if they underestimate the need
for supervision in their budget proposals - a serious professional concern in these
straitened times.

Summary

This chapter has explored the role and development of supervision when working with children
and young people, focusing on the following key issues:

e The supervisor of work with children and young people fulfils the same functions of ‘police-
man, plumber and poet’ as for supervision of adult work, but has to bear in mind the ways in
which these client groups are different
e Account has to be taken of the legal framework, systemic issues, child development, attach-
ment patterns and the communication styles used by children and young people
e The power/powerlessness issues of any therapeutic relationship, and hence any supervisory
relationship, are likely to be accentuated in this field
¢ Acrucial difference of this work is that it is even more difficult for the practitioner to stay with
the pain of children than it is to stay with that of adults, and the supervisee is likely to bring
powerful and complex feelings to supervision
e Children’s healing can be faster than that of adults, however, and seeing this brings great
reward to both practitioner and supervisor
SPARES RESTS LED GISRSEEOTE EBC ELESS BETSTITLE EES ESE TLSIO FRB EIST EEO IRIEL EEE EESTI IIS OER
 Supervision 209

Reflective Questions

1 As a supervisor how much do | need to be needed?

If you find yourself regularly providing, or wanting to provide your answers to your
supervisees’ practice situations, whose needs are you meeting? This response could be
an alert to considering how you are using your own supervision or peer consultation.

2 Do | feel uncomfortable setting limits?

As a supervisor you have a dual responsibility for the safety and potential for the well-
being of your supervisees and their clients, while holding a safe, open working space
with your supervisee. Monitoring limits of time, place and role becomes part of this
duality — have you considered this responsibility in your supervisory role?

3 What are the key elements of a supervision contract with a

supervisee working with children and young people?

Key elements of a supervision contract are the following:

For the supervisor and supervisee:

e Your membership of a professional body

e Your professional liability cover

Shared agreements:
e Time, place, frequency and payment for sessions
e Conditions of confidentiality

o Inwhat circumstances must confidentiality be broken, how will the client be informed?

e Name the key professionals and other adults with shared responsibility for the client, e.g.
link teacher, parent or carer.
e Identify the line of management accountability, e.g. service manager and/or head teacher.
e Stages of acomplaint’s procedure:

a) Mutual discussion to resolve the issue

b) If no resolution possible, refer the situation to management personnel and/or the
appropriate professional body, with the knowledge of each party.
210 The Handbook of Counselling Children & Young People

A a A a A SS!
ar
®
Learning Activities

For supervisor

Think of one of your supervisee’s clients and construct his or her family system as you
understand it at this moment, using objects or drawing a map with the client in the central
position. Use this in your supervision, or peer consultation, to clarify your own reactions
and ownership of issues.

For supervisor and supervisee

Evaluation Exercise:

e Design and use a questionnaire to focus on the purpose, model and outcomes of your
work in supervision for an agreed period, perhaps six months or a year.

Suggested Questions:

e What issues were raised in the supervision session?

e What approaches, exercises were used?
e How useful were they?
e How did the supervision session affect the work with the client?
é %

Further Reading

Houston, G. (1995) Supervision and Counselling. London:

The Rochester Foundation.
A small book, full of wisdom, in which more can be read on the ‘policeman, plumber, poet’
metaphor.

Landreth, G.L. (2002) Play Therapy: The Art of the Relationship. New York: Brunner-Routledge.
A very practical ‘Bible’ of non-directive play therapy, which combines theory with feeling and
which highlights the importance of self-awareness.

Karpman, S.B. (1968) ‘Fairy tales and script drama analysis, Transactional Analysis Bulletin 26 (1):
39-43.
Here more can be read about the power dynamics of the drama triangle.
 Supervision 211

Cowie, H. and Wallace, P. (2000) Peer Support in Action. London: SAGE.

For teachers and counsellors considering a school-based, peer support service. The chapter on
supervision is constructive, detailed and hands-on.

Online Resources

BACP website: www.bacp.co.uk/, especially

the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, particularly Module CMD 11: Using
Supervision.
 14
Group Work
Peter Pearce, Gwen Proud and Ros Sewell

This chapter includes:

e An outline of some of the key applications of group work with children and young people
e Anexploration of some of the benefits and advantages of this work
e Adescription of some of the considerations necessary for setting up group work
e Identification of many of the attributes required of a group facilitator as well as behaviours
that are not facilitative
e Details of some of the theoretical ideas about group work and group dynamics
e Asummary of the history and background for group work
e Apicture of current research on group work

Introduction

In a climate of limited resources, particularly one which can be dominated by concerns

about results and statistics, as within a school environment, therapeutic group work can
be seen as cost effective and time efficient. It can be attractive to stakeholders to know
that 12 people are being seen in a group. Groups might also be seen as a way to address
particular issues, for example bullying or anger management. So there may be consid-
erable pressure for group work to be offered. The key benefit of therapeutic group work
is that it results in interaction and social contact which does not occur in the individual
 Group Work 213

client and therapist model. In this way therapeutic groups can offer participants the
potential to develop their understanding of themselves and others by being in relation
to other group members. The social, interpersonal context for issues is played out live
through embodied experiencing. Groups can also become rich feedback environments
where any participant can be facilitative, not only the therapists, and this can support
increased self-awareness and awareness of what others see. It can be very validating and
potentially developmental for a participant who, because of previous experiences, may
feel they have nothing to offer others to begin to experience that they can be facilitative
and that they might receive something valuable for themselves in return.
In a group new responses and ways of being can be tried out in relative safety.
Participants have the opportunity to be more than the person they have come to be
known as, providing the opportunity for harsh introjects and conditions of worth to
be dissolved and offering important preparation for using newly learned behaviours in
other areas of their lives.
The facilitative conditions can begin to be ‘held’ and communicated by the group, as
participants begin to challenge and keep each other on track. Participants may also be
triggered by others’ material into a range of emotional responses, giving the opportunity
for vicarious learning and, particularly with young people, for building on emotional lit-
eracy. The effect of working in this way therefore can have a profound impact on personal
awareness and development. All of this makes group work a suitable choice for effective
work with children and young people in a variety of contexts such as schools and chil-
dren’s services, particularly when the problems are recurring, isolating and stigmatising.
Therapeutic group work involves the bringing together of a carefully selected group
of individuals to meet regularly with a therapist. The purpose of such work may include
to assist each individual in emotional growth and personal problem-solving to identify
and increase the use of strengths and to increase well-being.
Generally, therapeutic group work will be adopted for children and young people
whose problems relate to social and/or relational difficulties. It is about helping people
within a social setting to grow and develop their social skills, personal resources and
their relationships with other people. In the school setting, therapeutic group work
can have a variety of applications including prevention (e.g. peer pressure), problem-
focused (e.g. parental separation) and information-focused (e.g. study skills) with the
decision to offer group work often influenced by time constraints (Steen et al., 2007).
Small group work, facilitated by a mental health professional with knowledge and
experience of how to use the group process to promote the individual, can be a use-
ful intervention to attend to self-esteem and social difficulties. Within the group
context the group process is viewed as an integral agent for change in individuals.
Although beneficial outcomes can be achieved from educational and guidance
group interventions, a counselling/therapy approach, which addresses internal dif-
ficulties in an environment of support and group cohesiveness and enables freedom
214 The Handbook of Counselling Children & Young People

of self-expression, has the potential for greater intra-personal gains relating to self-
esteem and locus of control.
The culture of group work is somewhat informal, every member sitting in a circle,
though there will usually be in-built safe working practices, including mutually con-
sented boundaries and meeting in the same room, that provide privacy, appropriate
space for movement, light and resources.
Carl Rogers describes the group as an organism with an inherent actualising ten-
dency which means that, given a reasonably healthy psychological climate (i.e.
characterised by the presence of Rogers’ six conditions), the group will move towards
health. Facilitation of group work ensures a climate that is psychologically safe for the
participants through being authentic, offering empathic understanding and acceptance
of each individual, and the group itself.
During therapeutic group work, participants can begin to see that they are not alone
in experiencing difficulty in life and can find it comforting to hear that others have
similar difficulties, or have already worked through an issue that is problematic for
another group member. Yalom and Leszcz (2005) describe this therapeutic factor as
‘universality. Other therapeutic factors of group work identified by Yalom (Yalom and
Leszcz, 2005) include:

Therapeutic factor Definition

Altruism Participants gain a boost to self-concept through
extending help to other group participants
Instillation of hope Members recognise that other participants’ success can
be helpful and they develop optimism for their own
improvement
Imparting information Education or advice provided by the therapist or group
participants
Family re-enactment To re-enact critical family dynamics with the group; the
opportunity corrective recapitualisation of the participant’s primary
family experience
Development of The group provides participants with an environment
socialising techniques that fosters adaptive and effective communication
Imitative behaviour Participants expand their personal knowledge and skills
through the observation of group participants’ self-
exploration, working through and personal
development
 Group Work 215

Therapeutic factor Definition

Cohesiveness Feelings of trust, belonging and togetherness
experienced by the group participants
Existential factors Participants accept responsibility for life decisions
Catharsis Participants’ release of strong feelings about past or
present experiences
Interpersonal learning Participants gain personal insight about their
input interpersonal impact through feedback provided from
other participants
Interpersonal learning Participants provide an environment that allows
output participants to interact in a more adaptive manner
Self-understanding Participants gain insight into psychological motivation,
underlying behaviour and emotional reactions

Yaloms therapeutic factors are consensually accepted and remain widely debated and
researched.

Therapeutic Group Work as an Economic Intervention

A considerable benefit of the group modality is that professionals can work with a
larger group of young people at one time. This possibility offers a degree of relief in
child-based health-care systems which are often bound by restrictions on time and
resources. A particular benefit is the opportunity to alleviate pressure on waiting lists,
allowing clients to be seen sooner and helping prevent difficulties increasing or a decline
in coping that may occur during a long waiting period (Freeman et al., 2004).

Selecting Participants for Group Work

It is important to consider the basis on which individuals are brought together to work
in a group. Candidates for therapeutic group work should be offered a group that is
best suited for their identified needs. This is different from forming a group based ona
diagnosis or label. Consideration of the rights of children and young people, including
full and appropriate consent, need to be an integral part of the recruiting process.
In order that a therapeutic group is able to function effectively some care needs to be
given to group selection. Aspects that might need to be considered could include that
216 The Handbook of Counselling Children & Young People

need is compatible with the goals of the group, that the group is mixed (i.e. not a group
of young people all of whom have behavioural difficulties - which might be in danger
of entrenching existing self-images and become the ‘naughty boys’ group), motivation
to participate and capacity to perform given group tasks. It is also useful to have a bal-
ance between those who speak easily in a group and those who find it more difficult.
The size of groups can range from between five and 12 participants, but eight partici-
pants would generally be considered as the optimal size. Whilst therapeutic groups will
normally have one or two group facilitators, it is worth considering the benefits from hav-
ing two facilitators. Greater opportunity for observing and noting the group dynamics
is afforded, improved access to adult support when needed for certain tasks, less chance
of disruption should a facilitator be unable to be present for any reason and less chance
of leaving a group unattended in a situation that might require a facilitator to seek help.
It is recommended that prospective group work participants meet in advance with
group facilitators to determine suitability. This provides the opportunity for the group
facilitators to explain the purpose and format of group work and answer any questions
that will help in deciding whether to participate.

Attributes of a Group Facilitator

We have found that to be effective group facilitators with young people we have had to be:

e flexible, willing to start where the participants can

e willing to really hear the young people and honour each person’s unique contribution
and frame of reference
¢ willing to allow conflict in the room and support others to be okay with this too
e unafraid of the process and non-defensive
e able to stay in relation
e attentive to the process and sensitively observant
¢ open to welcome different parts of participants and open to people changing
e ‘inthe moment’
e equipped with a sense of humour
¢ willing participants in the group ourselves and consider self-disclosing when it feels
appropriate
¢ good advocates for the group outside of the group setting and represent it positively to
others
¢ mindful of child protection issues and safety in the group
¢ consistent in maintaining a quietly positive invitation to participants that signals hope
and welcomes potential
¢ warm, accepting and able to set clear boundaries
 Group Work 217

We have found that these attributes, that might all be part of one-to-one work or other
group work too, have needed to be developed further in this setting which can feel
more intense and issues amplified.
Corey (1981) identifies some behaviours which he sees as non-facilitative. These
include, giving frequent interventions, pushing or manipulating the group towards
their own unspoken goal, judging the success of a group by the dramatics (how
many people cried), acting as an expert with superior knowledge and withholding
of self, using ‘we’ statements, implying there is no free choice — ‘now we will do an
exercise, etc.

Life Cycle of the Group Dynamic in Group Work

Many theories exist about group work dynamics and life cycle. Though there is no
definitive model of group stage development it is generally considered that the group
process is fairly predictable and that therapeutic groups change and evolve over
time (Arrow et al., 2005). This process of change can help the therapist to determine
personal and group development as well and provides opportunity to evaluate and
formulate specific interventions. Tuckman (1965), Slavin (1997) and Lewin have
been highly influential in providing insight into the possible factors involved in
group dynamics.
Rogers believed that therapeutic potentiality was influenced by having trust in the
group process — ‘T rely on the wisdom of the group’ - with the group facilitators becom-
ing participants and having influence but not control. Rogers trusted in the group's
potential for recognising and dealing with unhealthy elements.
Studies of group development are generally consistent with the Tuckman model
which considers the developmental stages (from conception to the end) to be the most
significant dynamic. Tuckman identified five stages through which groups progress.
The first stage is ‘forming’ and involves a number of group participants experienc-
ing levels of uncertainty and anxiety, whilst others will experience feelings of positive
anticipation or even excitement. Expectations about what might happen in the group
will vary from member to member. Participants will be appraising how trustworthy or
safe the group feels for them and will generally be looking to the facilitator for guid-
ance. The second stage, ‘storming, involves the formation of a group identity and is
more challenging in character than the forming stage because of increased active par-
ticipation and the emergence of personalities ranging from dominant to withdrawn.
This is the time when the boundaries and skills of the facilitator will be tested and the
importance of tolerance and patience, and being able to demonstrate firmness, fairness
and support, will be imperative for the future triumph of the group. Tuckman’s third
218 The Handbook of Counselling Children & Young People

stage, ‘norming, involves participants having a sense of belonging, giving up their own
interests to the interests of the group, and establishing group ‘norms’ that enable a suf-
ficient sense of trust and safety. The resulting shift in the power dynamic means that
participants will begin to feel comfortable enough to work together on given tasks with
less reliance on the facilitator and will in effect be ‘performing. The final ‘adjourning/
mourning’ stage of the group process is concerned with the phase that includes ending
the group work when the work is completed and the group breaks up. This will present
varying levels of emotional challenge for participants depending upon their experi-
ence of change and former endings in their lives. Great consideration and care needs
to be given to participants during this phase. Preparing participants for the end of the
group work may include an acknowledgement and celebration of work accomplished
and completed, facilitating the expression of feelings about ending and engaging in
some kind of evaluation process.
The perspective of the group dynamic of Slavin differs from that of Tuckman with
its emphasis on the importance of individual behaviours of group participants and the
effect they have on the group dynamic. Individual participants begin to adopt roles
that influence the direction of learning and group process that will be significantly
impacted, for example, by the absence of a particular group member.
Lewin’s approach to therapeutic group work focused on group behaviour. Lewin was
responsible for coining the term ‘group dynamics’ and suggested that the individual
exists in a psychological field of forces. He revealed the impact of the group on the indi-
vidual and consequent change in behaviour followed by the individual then impacting
on the group, which he defined as ‘group pressure’.

History and Background

The therapeutic power inherent in groups was recognised in the early 1900s by Boston
physician Joseph Pratt working with impoverished sufferers of tuberculosis. Pratt ini-
tiated group intervention for his patients for efficiency purposes and learned from
observations that healing qualities emerged from the group process involving mutual
concern and learning. The efficacy of the work demonstrated by Pratt sparked an
interest in group work as a therapeutic intervention in the field of psychology based
on the dual belief that many individual problems are social in origin and that people
sharing a common problem can be helpful to each other. The formation of Alcoholics
Anonymous is a notable example. The ensuing widespread practice of group therapy
and the growing body of literature commending the benefits of group work resulted in
firmly establishing its practice across populations and settings.
The developmental roots of therapeutic group work with children and young people
are founded in the social and theoretical changes relating to psychology. A noteworthy
 Group Work 219

example is that of S.R. Slavson and his role in the establishment of the American Group
Psychotherapy Association. Slavson became interested in social group work within his
New York neighbourhood in 1911. His educational convictions, viewed as progressive,
determined the nature of the group work. In 1934 he introduced a child guidance clinic
for small groups of socially-alienated girls. Structured activities using arts and crafts
materials allowed complete freedom of self-expression devoid of any didactic or judge-
mental elements in the belief that self-expression and creativity are the key to human
happiness and constructive social adjustment.
From the 1950s great strides were made towards the development of group therapy
with increasing focus extending to other areas including education and child guid-
ance. A humanistic approach was brought to group psychotherapy by Dreikers, Adler
and Rogers and significant contributions by Corsini, Rosenberg and Berne, amongst
others, helped to illuminate the role of group dynamics and environment in successful
therapeutic outcomes.

Theoretical Underpinning

A person-centred or child-centred theoretical orientation provides an appropriate

context for group therapy and is in line with contemporary guidance and policy for
psychological interventions with children and young people (e.g. the UN Charter
on Children’s Rights). Therapeutic group work with children and young people is
rooted in the humanistic tradition of psychology and Carl Rogers’ theory of person-
centred practice which centres on the individual’s potential to be self-directive within
a facilitative environment. A doctoral student of Rogers, Virginia Axline (1947), out-
lined important child-centred principles for providing an effective framework for
group therapy practice. They include: that the therapist develops a warm, friendly
relationship with the child; the child is accepted exactly as he/she is; that only those
limitations that are necessary to anchor the therapy to the world of reality are estab-
lished; that the child is made aware of his/her responsibility in the relationship; that
a deep respect is maintained for the child’s ability to solve his/her own problems if
given an opportunity to do so; that the responsibility to make choices and to institute
change is the child’s.

Models of Group Contracting and Maintenance

As in all therapeutic work it is imperative to establish clear boundaries. At the outset

of group work the boundaries can be incorporated into a contract which involves
220 The Handbook of Counselling Children & Young People

participants of the group, including the facilitators, working together to produce

a statement, usually in writing, of the general responsibilities and expectations for
the course of the group work. As the group develops, it is possible that the contract
may need to be reviewed and revised to reflect altering conditions and expectations.
Revisions happen as a result of increased meaning and significance of the contract
for participants brought about from experiential learning and group process. Some
group contracting models require participants to sign the contract, agreeing to abide
by its conditions. A copy of the group contract is generally available for reference at
every session.
The content of the group contract should reflect that it is designed to provide a safe
and cohesive environment for participants including the valuing of one another. It may
include agreements about conflict resolution, attendance expectations, terms of with-
drawal from the group, confidentiality, physical contact limits, the right to ‘pass’ on an
activity and how feedback, evaluation and information are handled and shared.
Regular attendance and punctuality increase value for participants and contrib-
ute to creating a climate of cohesiveness and purpose. Participants may need to be
helped to appreciate that their participation makes an important contribution to
the group process and is therefore helpful not only personally but also to the other
group participants. Leaving a group is an important process because of the feelings
involved. The terms might usefully encourage discussion of any concerns a member
may have initially within the group so that efforts can be made to find a satisfactory
resolution.
An atmosphere of trust is essential for group participants to feel safe enough to share
material and disclose their feelings and problems. Participants should be asked not to
discuss anything outside the group, using the principle of ‘what is said in the group
stays in the group. It is the group facilitator’s job to help each member understand that
it is their responsibility to protect the names and identities of fellow group partici-
pants. At the same time, because sharing themes of the group work and their personal
material with significant others can be an important element of personal growth for
participants, the facilitator should not discourage it as long as it does not contravene
confidentiality boundaries. An element of safety can be provided by including the right
to ‘pass’ on any activity that may cause a member of the group to feel uncomfortable
and helps to establish trust that may enable fuller participation as confidence grows.
Contracting will also need to make clear the limitations of what can remain private
and that the group facilitators have an obligation under child safeguarding require-
ments to share with relevant parties any disclosures that indicate serious risk of harm.
Generally group contracts will specify that there should be no uninvited physical
contact. This is important because young people will have different personal histories
and interpretations of what touch means. Exceptions include drama and dance groups
where touch will form a natural and normative part of the group work.
 Group Work 221

Context of the Group

Therapeutic group work acknowledges that personal well-being depends to some

extent on how the individual constructs the self in social terms and the strong relation-
ship between emotion and social interaction. This approach takes a holistic view of the
complex range of human need, conceiving human problems in context.

Methods of Outcome Evaluation

Evaluating the outcomes of group therapy can be useful to determine whether the
intervention is suitable to a child’s needs and is achieving the goals that were identified
at assessment. An evaluation can provide important information on the effectiveness of
the content of group work as well as ideas for improvements. Essential characteristics of
outcomes evaluation include the use of reflective practice, clinical supervision, gather-
ing feedback from participants about their experience of the intervention, and overall
authoritative monitoring and assessment.
Evaluation may involve measuring numerous outcomes such as behaviour changes,
attainment of skills, group process, goal attainment, and participant satisfaction. It may
take the form both of quantitative and qualitative assessment measures and in work
with children and young people may also involve taking into account assessments
obtained from significant others such as parents and teachers. Debate surrounds this
practice because of the potential for bias and personal interest influencing assessment.

An Example of Therapeutic Group Work

The group was a closed group of 12 students and we met together for one and a half
terms. All the students were aged 14 to 15 years old and had been selected by their year
head for a variety of reasons. The presenting issues from the school’s perspective were
mainly behavioural issues which affected the school, for example ‘challenging behav-
iour, ‘withdrawn, ‘violent; ‘rude to staff’ ‘aggressive’ and ‘silly in class. With only this
information about the students the group was formed, so our beginning point with
this group was knowing their behavioural history at school but very little about them
as people. What unfolded in the group were the group members’ individual stories.
These were moving and helped us to make sense of their behavioural issues.
One of the challenges in this setting is to collect and assemble a group in the desig-
nated room. These particular students were drawn from a pool of students who were
222 The Handbook of Counselling Children & Young People

seen as ‘problem students’ — those who the staff found ‘difficult to work with. It was our
task to try to move the students through the school in a group. Moving around the school
together caused problems for other classes as the group were often shouting, disruptive
and knocking on classroom doors en route. This can present problems for counsellors
working within a school environment as the role of group facilitator may become com-
promised by enforcing discipline, and of course the rules of the environment need to
be respected if any group is to go ahead. The tension between these attitudes is always
present for a school counsellor and working with groups seems to highlight this issue.
Our experience with this particular group was that once we had arrived at the room
it was always difficult to begin. We would invite an opening circle. We found that by
asking each member of the circle to share the best and the worst part of their week
this helped to invite them to a reflective place. This process was a struggle to achieve.
During the opening circle, we modelled trying to listen respectfully whilst openly
acknowledging the difficulties of speaking over each other and striving to manage this
without being critical or telling the participants off. We were seeking to invite a differ-
ent experience of mutual respect for each other in the group, helping to create a safe
space where all the participants could share openly.

Gs The best bit of my week was ...

D: The best bit of his week was shagging his girlfriend.
(all the group participants laughing and commenting ‘whooo, yeah; etc.)
1D: Yeah — he thinks he’s fit, innit?
(all the group participants laughing and commenting ‘whooo, yeah; etc.)
( Shu’ up.
Dy): No, you shu’ up!
(the whole group just began taking sides and shouting ‘shu’up’ at each other)
We waited for a break in the shouting.
Peter: (to C, said with warmth) It didn't feel like you really got a chance to speak C
... do you want to carry on?
The therapist's response here was just enough to create some space and
allow the group to continue, and we were able to complete the opening
round. L was the first person to speak after the opening round. She told
the group that she had noticed how dark it was this morning on her way to
school and said how she hated it and it made her feel a bit ‘rotten’
Ji What d’you mean rotten?
li: Well ... a bit sad I think.
Ros: You feel a bit sad.
ibg Yeah sad, because it was in the winter when I had to go and live with my
Nan and she lives so far away from the school that I had to leave early when
it was dark ... (silence) and I think the dark reminds me of that time.
 Group Work 223

F: Why were you living with your Nan?

is It was when my Mum died.
(There was absolute silence while the whole group watched and listened
attentively and a palpable feeling of warmth and empathy entered the room)
GC: I didn't know your Mum had died.
(Various group members said ‘nor did I’, ‘how sad? ‘that’s awful’)
G: I don't know how to say this ... I just feel so sad for you ... and I want to say
... 'm here for you.
i (sat quietly for a while — then cried - L got up and moved towards C and
they hugged each other and the whole group cried together).

This example demonstrates the capacity that group members have for listening to each
other and for reaching out with empathy. The group moved from all shouting at each
other in the early part of the session to being able to be empathic without the need for
‘facilitation.

Research

A systematic scoping review for BACP (Harris and Pattison, 2004) reviews a number
of controlled trials and meta analyses that include group therapy interventions for chil-
dren and young people. Group play therapy (Bratton et al., 2005; Danger and Landreth,
2005), group CBT (Kaufman et al., 2005; Carpentier et al., 2006), school-based group
psychotherapy (Layne et al., 2008) and group humanistic and interpersonal therapies
(Shechtman and Pastor, 2005; Rossellé et al., 2008) all show some evidence of effec-
tiveness. Baskin et al. (2010), examining data from 107 studies, found that treatment
groups that were predominantly male or female did better than mixed gender groups
and suggest that the flexibility of schools to offer multi-faceted interventions seemed
to demonstrate an advantage of the school setting over mental health clinic settings. In
a randomised controlled trial by Stice et al. (2010), adolescents with mild to moderate
depression were randomised to either supportive group therapy vs. CBT group therapy
vs. CBT bibliotherapy vs. controls. In this study those who received supportive therapy
showed comparable benefits to those in CBT. These benefits were sustained at two year
follow-ups and were much better than the control group.
The BACP scoping review also identifies that future research needs to be rigorous
and transparent to capture the complexity of routine practice with this client group.
The authors recommend a wider range of research methodologies, attention to the
transfer of research findings into clinical settings, consideration of the relationship
between age and treatment outcome specifically adapting interventions to the differ-
ent developmental stages of adolescence and pre-adolescence, and research into the
 224 The Handbook of Counselling Children & Young People

long-term impact of interventions with children and young people. They also note
the relative absence of research relating to certain issues, particularly self-harm and
eating disorders.
In a recent research review of school-based counselling in UK secondary schools,
Cooper (2013) highlights that, both for young people themselves and other stakeholders,
there tends to be a preference for school-based counselling services that offer a wider
array of interventions beyond the one-to-one counselling setting. It further identifies
that there is evidence to suggest that mental health and well-being interventions are
more helpful when a ‘whole school’ approach is adopted, targeting interventions at the
wider school context and the groups within it, rather than just the individual young
person's problems and needs.
Cooper identifies how the extent to which counsellors can expand their services will
depend on the resources available but also identifies that there may also be issues of
training, and of how the school-based counsellor role is conceptualised.

Summary

e The key benefit of therapeutic group work is that it results in interaction and social contact
which does not occur in the individual client and therapist model
e The group context offers a method of intervention that acknowledges individual problems in
relation to the wider social world
e Therapeutic group work is a suitable intervention in a variety of contexts such as education
and family work for problem-solving, social skills building and addressing socially-constructed
problems
e An understanding of issues for children and young people and related mental health prob-
lems is necessary for implementing effective support
e Awareness of the emotional and social aspects of child development is important for under-
standing how social situations impact on child well-being
e Therapeutic group work acknowledges the relevance of group process as a helping technique
in personal development
e There are a variety of methods for measuring the outcomes of interventions. The choice of
method may be governed by available resources
e Preliminary discussion and preparation are key factors in conducting successful group work
e The environment in which therapeutic group work takes place needs to be supportive, with a
therapist whose approach is sensitive and respectful
e Feedback from group work participants and other interested parties is a necessary part of the
evaluation process and provides a cross-reference against group work aims and objectives
 Group Work 225

e Therapeutic group work has a proven record of significant benefit and is becoming a common
choice for therapeutic use. If introduced at a grass-roots level, such as within schools, it can
provide a great opportunity to address specific social and emotional needs preventatively to
support healthy development as part of a school well-being service

Reflective Questions

1 What kinds of characteristics are common to group work

development across different theories?

Common characteristics across theories include:

e that each group experience will be unique

e that each participant will experience group work in their own unique way
e thatthe culture and environment in which the group is set will impact on the experience.

2 When might therapeutic group work not be suitable?

If a child or young person is unable to engage because of issues of significant risk of

self-harm or suicide, or if the group setting cannot provide sufficient support to
contain their distress or behaviour this may preclude them from being able to engage
with or benefit from a therapeutic group setting.

3 What might be some of the advantages ofthe therapeutic

group?

As therapeutic group work is a social activity it has intrinsic advantages on two levels.
Humans are by nature social beings and working in a group is therefore within the
realms of natural human experience. Being part of a group provides access to a variety
of insights and experiences not possible in an individual setting. Working in a group
represents in microcosm the family, society, and civilisation.
226 The Handbook of Counselling Children & Young People

4 What are some of the ethical considerations of group work?

Group facilitators have responsibility for protecting the welfare of each individual
group member and for ensuring that the group as a whole functions in a way that
benefits everyone involved. The ethical concerns relevant to individual psychotherapy
apply in the same way in group work. Ethical issues specific to group work involve the
group selection process, screening, diversity and social contact amongst group partici-
pants outside of the group. An important ethical consideration is to determine member
compatibility with the goals of the group and for the potential member to determine
whether the group is compatible with their personal goals.
Group facilitators should be fully familiar with the ethical frameworks and guid-
ance of associated professional bodies. They are required to be sufficiently competent
to lead a group, have the adequate training, experience and qualifications necessary to
understand group process and be able to respond appropriately to the inevitable con-
flicts and challenges of group work. Adequate supervision needs to be sought by group
facilitators for the duration of the work. Great care needs to be given to planning the
work and recruitment of participants including ensuring their informed consent. A
clear understanding of how to deal with confidentiality and disclosure is needed along
with establishing and maintaining boundaries, minimising risks, managing premature
withdrawals from the group and ending the group in an ethically sound manner. Group
facilitators should be aware of their power in a group and careful not to impose their
own values on the group. They need to be mindful of the limits and appropriate use
of personal disclosure. Group session notes should not make reference to individual
group participants by name or other identifying information. There should be ade-
quate provision for follow-up of any issues arising out of the group work.

¢ é
Learning Activities

Scenarios - how would you respond?

1. The head has asked you to organise a group to address an escalation in bullying that has
been identified within the school.
N . Ayear head has given you a list of boys who really need to ‘work on their anger’ and asks
you to sort it out.
3. A group of girls, including one of your current clients, asks if they can all come together
to talk in a group.
4. A teacher who you know really values your work asks you to help her with her class
ee
Et
ma
mt
an
SE
ES
amy
=
a
tomorrow after registration as she needs to address their disruptive behaviour.
Re
Ee
ms
mm
mm
RE
a
=
¢ ee
 Group Work 227

ea" as = = 2 = = a ee oD

Group facilitator self-evaluation r

Ask yourself
the following questions:
i
e Am|!genuinely interested in people? i
e What personal needs are met by my being a group facilitator? i
e Am | authentically myself in the group, or do | have a need to direct the participants’ !
lives? '
e Am | willing to take time to understand others, or do | force them to follow my agenda? :
e Do | offer a proper model for what | hope and expect the members in my group to :
become? F
e What kind of model am |? (derived from Corey, 1981) Fl
® A

Further Reading

Bratton, S.C., Ray, D., Rhine, T. and Jones, L. (2005) ‘The efficacy of play therapy with children: A
meta-analytic review of treatment outcomes, Professional Psychology: Research and Practice,
36 (4): 376-390.
Carpentier, M.Y., Silovsky, J.F.and Chaffin, M. (2006)’Randomized trial of treatment for children with
sexual behaviour problems: 10-year follow-up’ Journal of Consulting and Clinical Psychology, 74
(3): 482-488.
Cooper, M. (2013) School-Based Counselling in UK Secondary Schools: A Review and Critical
Evaluation. Glasgow: University of Strathclyde.
Danger, S. and Landreth, G. (2005) ‘Child-centred group play therapy with children with speech
difficulties; International Journal of Play Therapy, 14 (1): 81-102.
Kaufman, N.K., Rohde, P., Seeley, J.R., et al. (2005) ‘Potential mediators of cognitive-behavioral
therapy for adolescents with co-morbid major depression and conduct disorder, Journal of
Consulting and Clinical Psychology, 73 (1): 38-46.
Layne, C.M., Saltzman, W.R., Poppleton L., et al. (2008) ‘Effectiveness of a school-based group
psychotherapy program for war exposed adolescents: A randomized controlled trial, Journal
of the American Academy of Child and Adolescent Psychiatry, 47 (9): 1048-1062.
McLaughlin, C., Holliday, C., Clarke, B. and Llie, S. (2013) Research on Counselling and Psychotherapy
with Children and Young People: ASystematic Scoping Review of Evidence for Its Effectiveness from
2003-2011. Lutterworth: BACP.

(Continued)
228 The Handbook of Counselling Children & Young People

(Continued)

Rossell6, J., Bernal, G. and Rivera-Medina, C. (2008) ‘Individual and group CBT and IPT for Puerto
Rican adolescents with depressive symptoms, Cultural Diversity and Ethnic Minority Psychology,
14 (3): 234-245.
Shechtman, Z. and Pastor, R. (2005) ‘Cognitive-behavioural and humanistic group treatment
for children with learning disabilities: A comparison of outcomes and process, Journal of
Counseling Psychology, 52 (3): 322-336.
Stice, E., Rohde, P., Gau, J.M. and Wade, E. (2010) ‘Efficacy trial of a brief cognitive-behavioral
depression prevention program for high-risk adolescents: Effects at 1- and 2-year follow-up,
Journal of Consulting and Clinical Psychology, 78: 856-867.
Westergaard, J. (2009) Effective Group Work with Young People. Berkshire: Open University Press.
Yalom, |.D. and Leszcz, M. (2005) The Theory and Practice of Group Psychotherapy. 5th edn. New
York: Basic Books.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially the modules on the Counselling
Context, CMD 0104-0108, and CMD 0110.
 Endings
Dee C. Ray

This chapter includes: ,

A review of outcome goals to guide the ending process in order to improve intentionality
when approaching the ending of the counselling relationship
Unique themes encountered by therapists in ending therapy with children, including develop-
mental and attachment considerations
Types of endings encountered in most counselling relationships and how to manage endings
when they come too soon
Affective elements that impact a therapist's decision-making and approach to ending and chil-
dren's affective and behavioural responses to ending counselling
Skills, scripts, and activities to facilitate the process of ending

Introduction

The purpose of this chapter is to explore the closing phase of the counselling relation-
ship specific to the developmental level of children and review attitudes, obstacles, and
skills related to effective approaches to ending.
As a therapist for over 20 years, I have experienced ending a great number of
therapeutic relationships with children. In my early career I worked with young ado-
lescents in a residential setting where endings varied from abrupt runaways to very
satisfying completion of therapeutic relationships. In later years, as a school counsellor,
my endings were often softened by the reassurance that I would see the children
230 The Handbook of Counselling Children & Young People

throughout the school day, even if I no longer engaged in counselling with them. And
in recent years, I have worked at a university-based counselling centre where I teach,
supervise and facilitate the counselling of children in an agency setting and a school
outreach programme. Currently, my role entails ending counselling relationships on
a weekly basis. As I supervise the ending of counselling relationships facilitated by
my supervisees and students and as I experience my own endings with children,
I recognise and honour the emotional process involved in this final stage of the
counsellor-child relationship.
Endings start at the beginning. The therapist's job is to facilitate expression and func-
tionality so that each child can move toward optimal development. The ending of therapy
must be part of the therapist’s vision at initial contact with a child. The therapist visualises
the child at a point in time when obstacles to growth are removed and the child pro-
gresses to a state of interdependent and healthy functioning. The therapist sees the end as
the real beginning for the child. Ironically, the goal of therapy is to end therapy.
Ending is typically viewed as the resolution of the counselling process. However,
closing therapy may possibly be an active part of the counselling process that allows
children to create meaning (Harrison, 2009) or experience new ways of coping with
loss (Many, 2009). Within the process of ending, the therapist and child collaborate
to make sense of the counselling relationship and develop new directions for growth.
Ending is the catalyst for the child’s movement into the world minus the extra emo-
tional and behavioural supports provided by the therapist.
Although the closing phase is critical to all endings of counselling with children, the
level of emphasis or time spent on ending is affected by several factors. First, endings
in more relationally-oriented treatment relationships necessitate more emphasis by the
therapist on the ending and loss of a meaningful relationship (Joyce et al., 2007). Brief
and skill-oriented therapies may require less reflection by both therapist and child.
Additionally, younger children may require less verbalisation and reflection on the
counselling process usually addressed in endings. Extensive talk and requests by the
therapist to verbally address the closing of therapy may be confusing and disconcerting
to young children due to their limited ability to grasp timelines. Finally, premature end-
ing initiated by a parent or managed care entity may influence a therapist’s presentation
and processing of ending with a child. Timing, emphasis, and approaches to endings
are addressed throughout this chapter.

Outcomes of Endings

Because ending is a phase of the therapeutic process, there are goals to guide this phase
just as there are goals for other stages of treatment. Joyce et al. (2007) identified three
outcomes related to successful endings in adult therapy that can be applied to working
with children, including the consolidation of therapy, resolution of relationship and
preparedness for progress.
 Endings 231

Consolidation of Therapy Process

The first outcome is consolidation of the therapy process and gains made in treatment.
When described within the context of adult therapy, this phase requires a review of
the therapeutic relationship since the beginning of therapy and self-assessment by the
client regarding changes in functioning. Although a verbal review of therapy would be
a meaningless task for a young child, this outcome can be addressed through skilful
therapist introduction of ending and the child’s natural response.

a ~\
Case Study Seth

Seth was a seven-year-old client who | saw over eight months for selective mutism. | introduced end-
ing in the following way, ‘Seth, do you remember when you first came here and you never talked at
school?’ Seth nodded. | continued, ‘And now you figured out how to feel good about talking at both
home and school? Also, you used to never talktome but now you talk to me a lot?” Seth nodded. He
said, ‘Now | talk all the time’! responded, ‘Yep, you sure do. Now that you're feeling good about your-
self and you can figure out ways to feel good about talking, | think that it’s time for us to stop seeing
each other. We'll have four more playtimes together’ Seth nodded and then responded, ‘I also used
to act like a dog but | don't do that anymore. | talk instead of bark’
The brief verbalisation by reviewing Seth’s progress served to consolidate Seth’s view of the
changes he made. Seth further acknowledged his growth by identifying a previous coping skill
that kept him from connecting to others (barking) that he replaced with a more functional skill
(talking).
Ase — ew

Resolution of Therapeutic Relationship

The second outcome of endings is the resolution of issues within the therapeutic rela-
tionship. In most cases, children develop intimate relationships with their therapists.
During the ending phase, the child will experience a sense of loss and will respond to
that loss. The success of this outcome is related to the child’s view of the therapist and
view of self outside of the relationship with the therapist.
In the session following the announcement of ending to Seth, I gave a five-minute
warning for the end of the session. He threatened to cut my neck with a rubber knife if
I stood up from my chair to leave. After threatening me a few times, I responded, “You
don't want me to leave, but our time is up for today’ He said, ‘I guess you can go. In our
second to final session, Seth painted a picture of a woman handing a bouquet of flowers
232 The Handbook of Counselling Children & Young People

to a child. He did not describe the picture but he presented it to me by saying, “This is
for you? Both the threats and painting were new behaviours for Seth in which he had
not engaged until ending was presented. These behaviours appeared to be his attempt
to let me go and acknowledge what he had been given in our relationship.

Preparedness for Progress

The third outcome of endings is related to the child’s preparedness for continuing pro-
gress and functioning following counselling (Joyce et al., 2007). For this outcome, the child
internalises the counselling process and the therapist's role in that process. In other words,
the child reveals self-reliance and confidence in abilities to work through future challenges.
In Seth’s final sessions, he initiated a new type of play with a toy he had not used prior
to the endings phase. Seth picked up a turtle and placed it in the sandbox. Seth drowned
the turtle in the sand and then brought the turtle back to the surface over and over again.
He verbalised, “This turtle just keeps coming back to life. The continued resurgence of
the turtle seemed to imply that Seth knew he was resilient and could thrive when things
get tough. He acknowledged his readiness to face the challenges before him.

Considerations for Child Endings

Development

A child’s understanding of ending is directly related to age and developmental stage.

In the preoperational stage of cognitive development (ages 2-6; Piaget, 1965 [1932]]),
a young child has difficulty grasping the permanence of loss and timelines set for an
impending loss. Giving a young child a five-week notice for ending of therapy may be
understood as a lengthy time period. If not reminded, the child is surprised by the quick
end of therapy and has difficulty managing the processing of ending. Yet, a child in
concrete cognitive operations (ages 6-12) may assume that if the counselling relation-
ship is ended, then logically she will never be able to see her counsellor again, leading to
significant grief. A therapist may need to reassure the child that the relationship can be
continued at a later point or the child can contact the therapist after ending.
Due to egocentricity states of children, children may feel that therapy is ending due to
something they have done wrong or that they have been bad in some way. Helping children
understand the reasons for ending therapy, and reminding them as needed throughout the
closing process, is one way to address a child's tendency to interpret events negatively (Moore
et al., 2008). Also, young children may often misunderstand the permanency of ending or
 Endings 233

they may come to understand permanency only after weeks of not seeing the therapist. They
may gleefully run out of the therapist's office with no goodbye after the last session. In these
cases, the therapist may send a note following the final session or suggest the parent facilitate
a note from the child to the therapist if the child needs to send alast goodbye.
Another factor related to endings and development is acknowledgement of the child’s need
to revisit issues related to treatment as they reach new developmental stages. Even if children
have progressed well through therapy, meeting all treatment goals, it is likely that they will
revisit old issues with each new developmental phase. In a case where a six-year-old child has
been sexually abused and the child has worked through fear and pain related to the abuse,
it is likely that the same child will revisit issues related to cognitive understanding of those
events when he reaches a concrete level of operations, attempting to make cognitive sense of
the situation. And again, when the same child reaches puberty, there may be a need for extra
support as the child attempts to understand self as a sexual being. Therapists help parents
understand that many issues related to child challenges are not simply resolved in one period
of time. There is a need to encourage parents to seek therapy when they see their children
struggling at subsequent developmental stages. In the ending phase of child treatment, the
therapist emphasises the fluidity of development and the likelihood of additional therapy.

Attachment

Endings are addressed sporadically and incompletely in the literature and endings in
child therapy are even less addressed. However, one element that is emphasised in the
few manuscripts addressing endings is the relationship between ending, attachment,
and loss. Joyce et al. (2007) claimed that a history of serious loss during critical develop-
mental periods increases the importance of endings for adult therapy. In humanistically
and psychodynamically-inclined therapies, the therapist works with diligence to facil-
itate a relationship with a child that emphasises trust, acceptance, genuineness, and
warmth. If a child is able to perceive these therapist attitudes, an attachment bond is
formed and valued. Ending is a direct threat to this bond and may cause feelings of
grief, loss, abandonment, anger or rejection (Moore et al., 2008).
Due to the fact that children presented to therapy typically have multiple risk factors,
often related to significant histories of loss and abandonment, the issue of attachment is a
key feature of treatment and endings (Many, 2009). Children seek the stability of a thera-
peutic relationship and are often positively responsive to such a relationship. When such
a relationship is established and treatment goals are met, a conflict ensues regarding how
therapy can end while the child maintains relational gains. Additionally, the child does not
just lose the therapeutic relationship but also loses the stability of therapy itself, such as the
therapy room, materials, rituals, and people related to therapy, such as administrative staff
(Zilberstein, 2008). The loss is relationally intense and structurally broad.
234 The Handbook of Counselling Children & Young People

Historically, the ending phase signified a definitive end to therapy. Therapists were
seen as crossing over professional boundaries with clients if they maintained contact
following the completion of therapy. In recent literature, it is suggested that a therapist
consider ending as transitional, not resolved (Zilberstein, 2008). Suggestions related to
addressing attachment issues within the ending phase offer the therapist various oppor-
tunities for contact with the child. A therapist may taper sessions from once a week to
once every two weeks to once a month as a move toward ending. Therapists may provide
follow-up sessions at various intervals to check-in with the child, such as once every six
months or year. Providing children with transitional objects such as pictures and crafts
during the ending phase is suggested. Additionally, a therapist may want to provide the
child with a way to contact the therapist following the closing of therapy through notes
or phone calls. With opportunity for subsequent contact, the therapist allows the child
to transition from the therapeutic relationship on a timeline that fits the child’s needs.
Both Many (2009) and Zilberstein (2008) suggest that a gradual and transitional
approach to ending offers a child with attachment difficulties an experience outside
of her reference, an opportunity for non-traumatic loss. While preparing the child for
loss, the therapist will also want to prepare the parent for the child’s loss. Collaborating
with parents regarding time and structure of closing offers parents an opportunity to
face their own losses and prepare to support their children. The parent’s acceptance of
the end of therapy helps them to model acceptance for the child.
The process and structure of endings has not been explored in the research. The
field of psychotherapy lacks knowledge on clients’ responses to endings or its effects on
counselling outcome. Although some counsellors believe that endings should be final
with no contact between therapist and clients, others believe that tapering of sessions
or continued contact after ending is the most effective way to close the counselling
process. Yet, there is no research to substantiate either practice.

Types of Endings

Natural Endings

In the ideal therapy world, therapy is completed when a child, parent, and therapist
agree that treatment goals have been met, emotional needs have been addressed, and the
child is ready to operate independently from the therapist. This leads to a natural end-
ing. Most child therapists experience natural endings in a minority of cases. Rarely do
therapists, parents and children come to the same conclusion at the same time. Natural
endings may be initiated by any of the three parties involved in therapy. Therapists
are probably the most likely to initiate a natural ending by highlighting therapeutic
progress with the parent and child. Children will often initiate ending through verbal
or behavioural signs such as ‘I want to go to football practice instead of coming here;
 Endings 235

or being bored in session. Parents are often hesitant to end therapy if progress has been
made due to fears of regression. They tend to address the topic of ending hesitantly: ‘I
think he’s doing better but I’m just not sure if this is the right time to end?

Premature Endings

Client/Parent-Initiated

Premature ending initiated by the client, more typically initiated by the parent in child
therapy, is also referred to as dropping out of therapy. The dropout rate is cited with a sub-
stantial range depending on individual studies but, on average, appears to be hovering at
approximately 50 per cent (Venable and Thompson, 1998). Often, therapy ends abruptly
at the will of the parent without therapist or child consent. The abrupt ending to therapy is
disconcerting for a child and may result in the child’s interpretation that she did something
wrong or that the therapist no longer wants to see her (Ray, 2011). Child therapists first
address endings in initial parent consultations, explaining the need for a planned approach
to ending therapy. When parents decide that ending is in order before the therapist or child
agrees, the therapist makes a concerted effort to contact the parent to plead the case for one
last session with the child. If parents do not concede to bring the child in for a last session,
the therapist may decide to send a note as one method of ending.

Example Note
Dear Michael, | am writing this note to tell you that | cherished our time together for
the last few weeks. |enjoyed talking with you and getting to know you. | hope that you
enjoy your karate lessons. Please take care of yourself and remember how special you
are. Thank you for sharing time with me. Suzanne

Research has focused on variables related to premature endings with children,

emphasising characteristics of clients that lead clients to end therapy early. Kazdin
and Mazurick (1994) found children at one site were more likely to prematurely end
therapy at early stages (six or fewer sessions) if children had higher impairment in
conduct, academic and social behaviours, parents were younger, children came from
a single-parent home, parents identified with a minority group, or parents reported
higher levels of stress. Children were more likely to prematurely end therapy at later
stages (7-14 sessions) if mothers were younger, children had a history of antisocial
problems, children had lower intellect scores, children were in a household with a
non-biological parent, or children had poor adaptive functioning reported at school.
Venable and Thompson (1998) found that caregivers who were highly self-critical or
236 The Handbook of Counselling Children & Young People

held personal guilt for the predicament of the child were more likely to initiate
premature endings. It appears that reasons for ending prematurely are cross-cultural,
as found by McCabe (2002), who reported that Mexican-American children were
more likely to drop out of therapy if parents had a lower level of education, perceived
barriers to treatment initially, believed that increased discipline addressed emotional
problems, or experienced lack of client-therapist ethnic match.
Children who dropped out of play therapy at one site were more likely to be from
single-parent homes, have younger mothers, or have mothers with lower levels of edu-
cation (Campbell et al., 2000). And parents at another site who had very high or very
low expectations for therapy were more likely to complete therapy while parents with
moderate expectations were most likely to end prematurely (Nock and Kazdin, 2001).
Overall, children with higher levels of behavioral problems were more likely to end
therapy prematurely (Tsai and Ray, 2011). This extensive research on premature end-
ings offers explanations for why child clients drop out from therapy early but it offers
no insight into best practices for the process of endings. Because endings are a sig-
nificant stage of therapy, there is a need for researchers to focus on variables related to
process and structure of the final stage of therapy.

Therapist-Initiated
When therapists initiate premature endings, typically referred to as forced endings, a client
is informed by the therapist that counselling will be ended even if treatment goals have not
been met. Forced endings are usually triggered by professional and personal changes in the
therapist’s life such as moves, new professional opportunities, or changes in family situa-
tions. Although forced endings are to be expected, they are particularly difficult to address
in child therapy. It is often hard for a child to understand that he will be losing his therapist
because she is having a baby or moving with a new partner. Forced endings are more likely
to be met with feelings of rejection by the child and feelings of guilt by the therapist.
Pearson (1998) and Bostic et al. (1996) suggested several implications for counselling
related to forced endings. Forced endings require the therapist to conduct a thorough
review of each child’s case and consider the child’s response to an unexpected ending.
If a therapist is open in sharing why he is leaving and where he is going, such openness
helps to soothe the child’s personalisation of the ending. Genuineness on the part of the
therapist by sharing emotions about leaving helps a child feel valued. Additionally, a
therapist should expect a child to respond in a variety of ways from apathy, to anger, to
sadness. The therapist is open to the child's response and need for expression of the loss.
Wittenberg (1999) emphasised the therapist's emotions of guilt, followed by defensive-
ness, that sometimes interfere with the therapist's ability to hold the child’s emotions.
Therapists benefit by recognising their own ambivalent feelings and consulting with
colleagues. Additionally, allowing children to have subsequent contact through notes
and letters can be helpful to the separation process. In the case of child therapy, Moore
 Endings 237

et al. (2008) cautioned against accepting children with attachment disruptions in ther-
apy if the therapist knows that treatment will end early due to forced ending situations.

Managed Care

Often, ending of therapy is decided by a third party who is uninvolved in the process yet a
decision-maker about length of therapy. In these cases, the therapist is typically aware of
the limited time for therapy at the beginning of the relationship. Although children may
be developmentally limited in their understanding of time, facilitating therapy under
management of an outside entity requires that children are fully informed of therapy
time limits from the beginning of the relationship. If only eight sessions are allowed, the
therapist should emphasise in the first session that ‘we will meet together eight times.
Clarity helps children understand the concreteness of the limitations. Just as in adult
therapy, children will make a choice consciously or unconsciously regarding how they
will use their time in therapy and the limitations of the therapeutic relationship.

Avoiding Endings

Child therapy is particularly susceptible to a therapist’s or child’s desire to prolong ther-

apy and avoid the ending of the relationship. Because children are in a constant state
of development, therapists might aspire to be involved in each developmental stage or
issue to ensure the child is progressing well. There is a tendency for some therapists to
prolong therapy until the child’s situation is ‘perfect’ - waiting for the parents to estab-
lish complete stability or the school to offer a perfect learning environment. Moore et
al. (2008) warned that prolonging therapy may be motivated by a therapist’s personal
issues and may inadvertently undermine the independent functioning of the child and
parent. Boyer and Hoffman (1993) found that counsellors were more anxious regard-
ing endings if they had a personal history of loss or if they perceived the client would
be sensitive to loss. Knowing that almost all children are sensitive to loss, especially
children with attachment issues, may inspire therapists to continue therapy beyond
necessity. In supervision of new therapists, I often find that they must be prompted to
end therapy when it appears that treatment goals have been met. Often therapists feel
that they provide the only predictable stability in the child’s life and hesitate to end the
relationship. Such feelings prompt discussion about the therapist's role in the child's
life and counter transference issues. With supervision or consulting support, therapists
work through their hesitancies and intervene for the benefit of the child.
A child’s hesitancy or reaction to ending therapy is complicated. As a normal reaction to
ending, a child might regress in behaviour and emotions, reverting back to negative coping
238 The Handbook of Counselling Children & Young People

skills used in the beginning of the relationship. Often, the therapist can be reassured that
this is a natural response to ending the relationship and the child will return quickly
to the new behaviours acquired during therapy. Yet, children often seem to organically
know what is in their best interests when provided with a stable and emotionally-sup-
portive environment. Hence, when it appears that a child does not want to end therapy,
the therapist needs to ask if she should take the child’s lead and extend the relationship. A
close attunement between therapist and child, along with the therapist's trust in the child,
typically result in most effective therapeutic judgement. If consideration of all factors
does not clarify the therapist’s direction, a therapist may want to offer ending as a break
for a few weeks instead of ending therapy permanently. Interrupting therapy for one or
two months may provide clarity regarding the child’s readiness for ending.

Approaches to Endings

Timing

There is no clear timeline suggested for the ending phase of child counselling. Some have
suggested two to three sessions (Moore et al., 2008), yet others encourage four to six
months (Wittenberg, 1999). Adult therapy guidelines tend to indicate that the longer a
therapy relationship has been established, the longer time is needed for termination. Yet,
developmental considerations of children indicate that drawn out periods of endings may
actually induce anxiety. Knowledge and attunement with the child, as well as a collabora-
tive relationship with parents, help inform the therapist in decision-making about ending
timelines. However, a minimum of three to five sessions is encouraged for most children.
Additionally, the view of endings as a transitional period for children may also influence a
therapist's approach to timing. For example, an endings phase of frequent weekly sessions
may be shorter if the therapist plans to taper to monthly sessions.

Preparing Parents

Parents are often hesitant to end therapy, especially if they have established a trust-
ing and stable relationship with the therapist just as their child has. In these cases, the
therapist has become part of the family system and it is difficult for the parents to visu-
alise themselves without the support of the therapist. The therapist presents the subject
of ending to the parent before the subject is approached with the child. The therapist
may need to provide several sessions of support to the parent in preparation of ending.
During this time, the parent is advised to not inform the child of impending ending
until the parent is confident about the ending of therapy.
 Endings 239

In some cases, the ending phase will consist of reminding the parent of the skills s/he
acquired over the time of therapy and continuing to bring up the inevitability of end-
ing. Meetings with the parent may become more frequent to provide emotional support
for ending. Once the parent agrees to ending, the therapist will introduce ending to the
child. Therapists are very encouraging during this phase of therapy, reminding parents
of their growth that correlated with the child’s development. The therapist will discuss
options for returning if the parent feels that the child is in need of therapy following
closure of therapy.

Preparing the Child

The therapist needs to offer a developmentally appropriate explanation for ending

therapy. Although some children may be unable to process extensively, they may be
able to connect behaviours with new situations, indicating that they have integrated
a newly revised sense of self. Child therapists are often surprised, sometimes disap-
pointed, by a child's reaction to endings. A child may respond with a simple ‘okay’ and
it is never spoken of again. At the last session, the child may simply wave goodbye to
the therapist without any demonstrative sadness or upset. Although this may be hurtful
to the therapist's feelings or bruising to the ego, this type of ending is developmentally
appropriate. In addition, a simple ending to the relationship indicates that the child was
ready to end and progress to the next stages of self-actualisation without dependence
on the therapist.

Activities and Gifts

Child therapists will often ask if they should give the child something or do
something different in session to mark endings. If the therapist decides to do
something to mark the ending of therapy, it is purely for the therapist, not for the
client. Creating crafts, exchanging gifts, and hosting parties are common ritu-
als indicating the end of the therapeutic relationship. Generally, large gifts are
discouraged but sharing small gifts is often understood as a cultural custom. The
most essential element to activities that address endings is a focus on the ending
of the therapeutic relationship. An ending activity should represent the value of
both people within the relationship and a celebration of what each has contributed
to the relationship. This celebration may include shared drawings, photographs,
or notes.
Children may want to give something to the therapist to mark an ending. In these
cases, if the child asks first, “What do you want me to give you for our last time?; I
 240 The Handbook of Counselling Children & Young People

will respond, ‘Anything that you make is something I will like’ If a child wants to
celebrate the ending of the relationship with a symbolic token, I truly want to participate
in that celebration. I attempt to avoid any encouragement for the child to buy a gift
but if a child arrives at our last session with a gift (of small monetary value), I will
usually accept such a gift as a way of honouring the child’s intention. Whether the
child acknowledges ending or not, I commemorate our relationship by taking a few
minutes to review the child’s file by reading through all the documents in a personal
way before filing my final treatment summary.

Summary

Ending counselling with children is a significant undertaking within the therapeutic relation-
ship. Endings involve the consideration of specific outcomes such as the need for integration of
changes adopted by the child during counselling, synthesis of the counsellor—child relationship,
and acceptance that closing of therapy is the beginning, not the end. Some key points to remem-
ber from this chapter include:

e Due to developmental and attachment factors, counselling endings with children require a high
level of personal awareness by the therapist, as well as ability to respond affectively and effectively
to children’s reactions to the endings phase. Emphasis and timing of endings are influenced by
the significance of the therapeutic relationship and the counsellor’s attunement to child needs
e Endings involve goals that address the affirmation of the counselling process, resolution of the
relationship between counsellor and child and preparation for the child’s progress following
counselling
e Types of endings include natural endings, that take place when therapeutic goals are met and
a child is ready for ending, and premature endings, which may be required when a parent
withdraws a child from counselling or a counsellor ends therapy prior to a natural ending. A
counsellor seeks to prepare a client according to the experienced type of ending
e In contrast to historical approaches to endings, new ways of conceptualising the end-
ing of counselling involve possible ongoing contact between therapist and child to
address issues of loss and independence
e Activities or shared gifts may be ways to help a child and counsellor commemorate their
shared relationship and offer a symbolic gesture of care to one another when ending a thera-
peutic relationship
e The ending of the counselling relationship can be the catalyst for effective relationships over
the lifetime of a child. Hence, a counsellor is most therapeutic when acknowledging the end-
ing of counselling as an essential part of the therapeutic relationship
 Endings 241

Reflective Questions

1 What are the implications of working with children who have

significant attachment problems regarding endings? How might
a past history of attachment disruptions negatively affect the
ending process?

In the process of therapy, children with a history of attachment disruptions are slow
to develop meaningful and effective therapeutic relationships with counsellors. When
they finally develop these types of relationships, it may be their first time to have such
a relationship with anyone. Endings with children with attachment disruptions may
likely be characterised by a child’s tendency to withdraw, become depressed or angry,
or revert to apathy toward the counsellor.

2 How do endings of counselling with children differ from endings

with adults? How would’a therapist approach endings differently
with children?

Endings with children are different from endings with adults due to developmen-
tal stages of life. First, the child’s understanding of time is different from an adult’.
Secondly, the context of endings is new to a child. Because of greater experience, an
adult is more likely to understand circumstances such as a therapist moving to another
job. Even if a therapist explains the necessity of ending, the child is more likely to inter-
pret the ending as being related to something the child has done or said. These types of
interpretations need to be worked through during the final sessions as the child comes
to understand that ending of therapy does not mean that there is something wrong
with him or her.

3 How can a therapist react in an effective way to premature

endings in the three identified situations: parent-initiated
endings, managed care endings, and therapist-initiated endings?

A therapist is more effective when endings are addressed at the beginning of the coun-
selling relationship. At first contact, the therapist emphasises the need for parents to
share concerns as soon as they develop. The therapist also emphasises the importance
242 The Handbook of Counselling Children & Young People

of allowing several sessions for endings to occur. If parents are certain about ending,
the therapist will ask for at least three to four more sessions for a proper closing to
therapy.

4 What is your history of personal loss? How might this affect your
approach to endings?

A therapist’s personal history of loss has great impact on the therapist's approach to
termination. If a therapist has experienced multiple losses but has not undergone per-
sonal therapy, the therapist may transfer these experiences to the counsellor—client
relationship.

5 What is your reaction to conceptualising endings as a transition,

not an ending? What effect, if any, will this conceptualisation
have on your approach to endings?

A therapist may be impacted by the structure of endings. The finality of a closing ses-
sion with no further contact will feel disruptive to some therapists while the tapering
of sessions or further contact after therapy will cause some therapists to feel that the
relationship is deteriorating, not ending.

Pt Sap, =F Saye ane A ae eee Sra ie, Gee ae rear tea ed met Ere ee pe LS

Learning Activities

1. Imagine you have been seeing a child for six months in therapy. The child had a signifi-
cant history of loss and abandonment and has made great gains in therapy. Write an
ending note to the child.
2. With a partner, practise presenting the ending phase to the same child.
3. With a partner, practise presenting the ending phase to a parent of a child you have
seen for three months.
4. Imagine you have seen a child for six weeks in therapy and the parent meets with you to
tell you that she is dissatisfied with therapy and will not be bringing her child back. With
a partner, practise what you would say to that parent.
5. Create a shared ending activity and role-play the activity with a partner.
=_— oe ess
 Endings 243

Further Reading

Joyce, A., Piper, W., Ogrodniczuk, J. and Klein, R. (2007) Termination in Psychotherapy: A
Psychodynamic Model of Processes and Outcomes. Washington, DC: American Psychological
Association.
Landreth, G.L. (2012) Play Therapy: The Art of the Relationship. 3rd edn. New York: Routledge.
Novick, J. and Novick, K. (2006) Good Goodbyes: Knowing How to End in Psychotherapy and
Psychoanalysis. Lanham, MD: Jason Aronson.
O’Donohue, W. and Cucciare, M. (eds) (2008) Terminating Psychotherapy:A Clinician’s Guide. New
York: Routledge.
Ray, D. (2011) Advanced Play Therapy: Essential Conditions, Knowledge, and Skills for Child Practice.
New York: Routledge.
Wilson, K., Kendrick, P. and Ryan, V. (2001) Play Therapy: ANon-Directive Approach for Children and
Adolescents. London: Bailliere Tindall.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially Module CMD 10: Concluding
Counselling.
 Evaluating Counselling
Katherine McArthur and Mick Cooper

This chapter includes:

———————————EEEE
e The experience of evaluation for clients and therapists
e The impact of evaluation on therapeutic outcomes
e The inter-relationship between research and practice
e Evidence-based practice and practice-based evidence
e Outcome and process feedback
e Qualitative and quantitative evaluation methods

Introduction

Across both child and adult services, there are many counsellors — particularly those
of a more relational orientation — who are disinclined to participate in formal out-
come evaluation (Daniel and McLeod, 2006); and this reluctance has been noted
by the Department of Health’s Improving Access to Psychological Therapies (IAPT)
programme (Wheeler and Elliott, 2008; DoH, 2008b). In spite of this, evaluation of
therapeutic outcomes is often necessary for counselling services to secure and retain
funding, and is often seen by stakeholders as essential.

The Experience of Evaluation for Clients and Therapists

Research suggests that the evaluation process may be a positive experience for both
clients and therapists. Recent studies in the context of school-based counselling, for
 Evaluating Counselling 245

instance, have shown that young people report positive responses to completing psy-
chometric measures at regular intervals before, during, and after counselling (Hanley
et al., 2011; Cooper et al., 2010). Indeed, a recent interview study of young people
allocated to the waiting list condition of a randomised controlled trial of school-based
counselling (Daniunaite et al., 2012) found that these participants were able to make
substantial progress from participation in the research project alone — without an active
counselling intervention.
From the practitioners’ perspective too, a Northern Irish study showed that the
process of participating in a large-scale school counselling evaluation garnered consid-
erable benefits for practice and professional development, although the experience was
described as challenging (Tracey et al., 2009).

The Impact of Evaluation on Therapeutic Outcomes

There is also growing evidence that evaluation improves therapeutic outcomes. In the
field of adult psychotherapy, Lambert and Shimokawa (2011) recently published a meta-
analysis of studies investigating the effects of providing systematic feedback to clients.
Their results showed that clients who are given systematic feedback on progress were
3.5 times more likely to experience reliable positive change, and had less than half the
chance of deteriorating, when compared with clients who received no formal feedback.
The potentially therapeutic effects of research also appear to extend to young
people in counselling. For example, Saunders and Rey (2011) found that screening and
assessment procedures contributed to improvement for 12-25-year-olds with alcohol
problems. A recent evaluation study (Cooper et al., 2014) on school-based counsel-
ling for young people obtained a substantially larger effect size for counselling (1.26;
see Box 16.1) than the mean weighted effect size (0.81) calculated in a comprehensive
meta-analysis of UK audit and evaluation studies (Cooper, 2009b). The key differ-
ence between this and previous evaluation studies was that counsellors administered
weekly session by session outcome measures. This suggests that completing measures
at every session, as opposed to only at the beginning and end of the entire counselling
period, may improve outcomes for young people in school-based counselling. In fact,
the results of another recent study of school-based counselling using systematic feed-
back with children as young as seven suggest that feedback may as much as double the
impact on reducing psychological distress (Cooper et al., 2012).

The Inter-Relationship between Research and Practice

Research activity among counselling practitioners is now widely encouraged, and coun-
sellors in training are expected to develop interest in research evidence and understanding
246 The Handbook of Counselling Children & Young People

of methods with a view to actively participating and securing the future of counselling
as a profession (Dunnet et al., 2007; Wheeler and Elliott, 2008). Outcomes of counselling
with children and young people, in particular, has seen a flourish of research interest,
and the BACP (British Association for Counselling and Psychotherapy) have recently
launched a Practice-Research Network specifically dedicated to this area: CYP PRN. Its
aims and objectives include promoting the inter-relationship of research and practice and
creating a sustainable network of practitioner-researchers to engage in ethical practice-
based research.
Wheeler and Elliott (2008) outline three key questions for the evaluation of prac-
tice: 1) Do clients change substantially over the course of counselling? 2) Is counselling
substantially responsible for these changes? 3) What specific aspects of counselling con-
tribute to client change? Adequately answering these questions, and the many further
questions that they inspire, requires that they are addressed from a range of different
perspectives, using a range of different tools.

Evidence-Based Practice and Practice-Based Evidence

Although the counselling and psychotherapy field requires rigorously controlled

research, designed to meet the demand for evidence-based practice, this must be
balanced with the real world perspective provided by practice-based evidence.
Evidence-based practice is a philosophical approach used in medicine and gaining
ground in counselling and psychotherapy, whereby empirical research is systemati-
cally reviewed to develop practice guidelines, on which clinical decisions are based.
Research studies are selected and interpreted according to specific methodological
criteria governing what constitutes ‘evidence’ Research is considered on a spectrum
of rigorousness, typically leading to qualitative data (which may be considered anec-
dotal) being disregarded in favour of quantitative studies conducted according to
strict methodological criteria.
Practice-based evidence is one way of informing evidence-based practice, rather
than an opposing concept. It is the exercise of drawing evidence from practice settings
in order to take this into account along with data from controlled experimental stud-
ies to form the basis for clinical decision making. In other words, rigorous research
is conducted in routine clinical practice, and this evidence feeds into decisions about
clinical practice.
In established counselling services for children and young people, outcome meas-
ures can easily be incorporated into everyday practice, resulting in the potential to
generate a large body of evaluation data which can be a powerful aid to the interpreta-
tion and application of evidence.
 Evaluating Counselling 247

Outcome and Process Feedback

Outcome feedback is the process of monitoring change in individuals, with the aim of
using this information systematically to improve practice. In counselling, it is compli-
cated by the fact that practitioner-researchers from different theoretical approaches
may have different aims and different concepts of ‘improvement’ for clients. For
instance, cognitive-behavioural therapy aims to address specific problems, such as
obsessive-compulsive behaviour, and measures its outcomes accordingly. Conversely,
person-centred counselling focuses on the client’s intrinsic needs and wants and may
be more appropriately tested by measuring overall well-being. Typically, outcome
measures used to evaluate counselling interventions focus on constructs such as psy-
chological distress, or difficulties. Some have a more ‘positive’ focus, attempting to
measure well-being or achievement of personal goals.

Box16.1_ Effect Sizes

Even when different outcome measures are used in evaluation studies, direct compari-
sons can be made between them by calculating standardised ‘effect sizes, which is a
way of reporting the amount of change observed. The most common effect size in the
counselling and psychotherapy literature is Cohen’s d, which is the amount of differ-
ence between two groups on some variable (for instance, pre- and post-counselling
scores on the CORE-OM), divided by their’standard deviation’(ameasure of the amount
of variability across scores).
Cohen (1988) proposed that in the social sciences, standardised effect sizes can be
understood in the following way:

Small effect = .2

Medium effect = .5

Large effect = .8

In addition to the specific outcome measure used, decisions regarding when and
how to administer these measures influence the results of outcome studies, and must
be carefully considered. Traditionally, measures are taken before counselling begins,
and immediately after it ends. This approach allows practitioner-researchers to assess
the amount of change that has occurred in a given domain (according to the specific
248 The Handbook of Counselling Children & Young People

outcome measure used) during the counselling period. However, a key recommenda-
tion for practice research networks like CYP PRN is for members to routinely collect
data from all clients on a session-by-session basis (Parry et al., 2010; Clark et al.,
2008) rather than only at the beginning and end of counselling. One reason for this
recommendation is that weekly monitoring allows practitioner-researchers to col-
lect more robust evaluation data than pre-post measurements alone. The majority of
practice-based evidence is limited by the problem of missing data (Stiles et al., 2008),
and this is true of school-based counselling studies too (Cooper, 2009b). Crucially,
when measurements are taken at the beginning and end of counselling only, the end-
point data collected comes exclusively from clients who participated in a planned
ending with the counsellor. Cooper (2009b) found that in school-based counselling
studies, the mean response rate was less than 65 per cent, suggesting that a large
proportion of young clients are not represented by these studies due to dropping
out of counselling before completing endpoint questionnaires. This means that cal-
culated effect sizes cannot accurately reflect the whole population of young people
in school-based counselling. This is a particularly pressing problem given that those
who complete counselling tend to have better outcomes (e.g. Wierzbicki and Pekarik,
1993). Using weekly outcome monitoring ensures that data is available for all clients,
producing more reliable evidence. Therefore, studies which use weekly session by
session monitoring overcome one of the major limitations of practice-based research
and have a greater chance of influencing clinical guidelines.
Some of the most frequently used tools for evaluating counselling with children and
young people are detailed in Table 16.1.
As noted, clients in general tend to respond positively to outcome measures, and
some may have additional benefits. For instance, the opportunity to collaborate on
goals with a counsellor, which is part of completing the Goal-Based Outcome Record,
has been shown to improve outcomes for clients (Iryon and Winograd, 2002).
As well as outcome measures, questionnaires are available to investigate the thera-
peutic process and clients’ experiences in counselling. One of the most commonly
used tools here is the Child Session Rating Scale (CSRS), which invites children
and young people to rate the extent to which they felt listened to in the therapeutic
work, and the degree to which the work met their personal needs and preferences
(Duncan et al., 2006). In addition, satisfaction questionnaires such as the Experience
of Service Questionnaire (developed for children and young people by Bury NHS
Trust) can give valuable insight into clients’ views of counselling. This measure asks
young people to rate their experience of a service on 12 items related to satisfaction,
such as ‘I feel that the people who saw me listened to me. Both of these measures
are available to download from CORC (CAMHS Outcome Research Consortium) at
www.corc.uk.net/resources/downloads/.
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252 The Handbook of Counselling Children & Young People

Qualitative and Quantitative Evaluation Methods

While outcome studies focus on quantitative data taken from psychometric measures,
qualitative data can also have a role in evaluation. Conducting semi-structured inter-
views is a potential way of collecting clients’ views about the outcomes of therapy, and
can provide a more in-depth perspective than psychometric measures. While outcome
measures give valuable information about effectiveness and appear to have benefits for
young people in their own right, combining this kind of data with qualitative records
from children and young people can enrich and support findings, providing crucial
depth and context to our understanding of the counselling process. This form of inter-
viewing generally involves using a pre-set series of open-ended questions and prompts,
and allowing the respondent to take the conversation in new directions as they come
up. Robert Elliott (1999) designed an interview schedule entitled the Client Change
Interview, which asks clients whether and how they feel they have changed since begin-
ning counselling, to what they attribute the change and how much it has impacted on
their lives, as well as covering the client’s overall experience of counselling. This has
recently been adapted for use with young people in school-based counselling (Lynass
et al., 2012).
Once semi-structured interviews have been conducted and transcribed, they can
be analysed in various ways. Thematic analysis is a commonly employed method,
and involves searching text for emerging themes and categories of responses (Guest
et al., 2012). Using this approach, Lynass et al. (2012) found that young people
in school-based counselling tended to experience positive changes in emotional,
interpersonal and behavioural domains. When asked about the helpful aspects of
counselling, young people mentioned talking and ‘getting things out’, as well as
specific counsellor qualities.
A different approach to qualitative data is discourse analysis, which investi-
gates a text on the level of underlying meanings as opposed to face value. A recent
example of this method is Prior’s (2012) investigation of how young people man-
age stigma in relation to accessing a school counselling service. He described how
young clients demonstrated critical views of help-seeking, which they had internal-
ised, before going through a process of reformulating those critical views, so that
they came to see their own behaviour (seeking counselling) as a sign of strength
and self-empowerment.
Randomised controlled trials (RCTs) are the most politically powerful method
of evaluation in health research, since clinical guidelines groups (such as NICE,
the National Institute for Health and Clinical Excellence, and SIGN, the Scottish
Intercollegiate Guidelines Network) primarily draw on RCTs to develop guidelines for
 Evaluating Counselling 253

evidence-based practice. The basic principle is that quantitative measures are taken
from a sample of participants (the larger the sample, the more powerful the trial), who
are then randomly allocated to two or more conditions: the treatment under investiga-
tion, and a control (or controls), which either involves not receiving the treatment, or
receiving a comparative treatment. Then measures taken from both groups at the end
of the trial period are compared to assess differences, which are assumed to be solely
caused by the treatment(s) under investigation, since random allocation is assumed to
control for individual differences. One recent RCT (McArthur et al., 2013) compared
YP-CORE scores from young people who attended school-based counselling with
those of young people who were on a waiting list, and found that those in counselling
showed significantly more improvement in psychological distress.

Summary

e Measuring outcomes of counselling is increasingly necessary to secure funding

e Outcome research appears to have considerable benefits for clients and counsellors
e Weekly outcome monitoring has further benefits for creating a robust evidence base
e Awide range of measures are available for children and young people
e Evaluation methods available to counselling practitioner-researchers are both qualitative and
quantitative
e Counsellors interested in becoming more involved in research can benefit from prac-
tice-research networks

Reflective Questions

1 How and why might research in various forms contribute to

therapeutic change for children and young people?

Some young people say that being asked about their experiences in a research inter-
view, or on a questionnaire, makes them start to reflect on their lives in a way that
they hadn't before, and that this leads to realisations about themselves and what
they want, which helps to make positive changes. It may also be that taking part in
research makes people feel that they are contributing something positive, helping the
researchers and the wider population, and that this helps young people to feel better
about themselves.
254 The Handbook of Counselling Children & Young People

2 How easy is it to incorporate an evaluation project into an

existing service? What might be the impact of this for a service?

Evaluation can be incorporated in different ways, and to different degrees. As a mini-

mum, completing an outcome measure before and after a period of counselling can
provide useful information on change. Using measures at every session gives much
more in depth data, which can be used to give detailed feedback to clients and/or
counsellors.

3 What might be the barriers to introducing evaluation to a

service, and how might they be overcome?

Some counsellors may feel that evaluation of outcomes impedes their work with clients.
It is important that counsellors feel confident with any evaluation tools before using
them with clients, and have the opportunity to discuss and explore their experience of
evaluation with a supervisor.

a ¢
i Learning Activities
L

t 1. Join the BACP CYP Practice Research Network (PRN): www.bacp.co.uk/schools/

2. Work through the three Counselling MindEd e-learning modules on Using Measures
' (CMD 06, freely available through www.counsellingminded.com)
; 3. Download some examples of measures from www.corc.uk.net/resources/. What do you
i think of them? How do you feel about completing them? Do you prefer some to others,
1 and if so why? If possible, role play how you might use these measures while counselling
i a child or young person. What impact do you think they might have?
! 4. Download the Goal-Based Outcome Record from www.corc.uk.net/resources/meas-
i ures/practitioner/. Imagine you are a client beginning therapy, being asked what things
i you would like to achieve by the end. What kind of goals would you set yourself? How
: does it feel to compose and rate these life goals?
: 5. Try to design a research project to investigate any aspect of counselling children and
' young people. This could be a project to evaluate an entire service, or focus more spe-
i cifically on your own practice. What would you want to find out? How would you go
i about it? What ethical issues might it raise?
* = Sms mses
 Evaluating Counselling 255

Further Reading

McLeod, J. (2003) Doing Counselling Research. London: SAGE.

Sanders, P. and Wilkins, P. (2010) First Steps in Practitioner Research: A guide to understanding and
doing research for helping practitioners. Ross-on-Wye: PCCS Books.
For counselling practitioners or trainees who are new to research, and interested in getting
involved, these introductory texts are ideal. They explain the basic principles in an accessible
manner, covering quantitative and qualitative methods, and include practical advice on ethical
considerations, getting started, and ways of presenting research to others.

Fraser, S., Lewis, V., Ding, S., Kellett, M. and Robinson, C. (eds) (2004) Doing Research with Children
and Young People. London: SAGE.
This text provides information and advice on the specific issues relating to research with children
and young people.

McLaughlin, C., Holliday, C., Clarke, B. and llie, S. (2013) Research on Counselling and Psychotherapy
with Children and Young People: A Systematic Scoping Review of the Evidence for its Effectiveness
from 2003-2011. Rugby: BACP.
This report provides an excellent grounding in counselling research conducted with children
and young people, which is essential to planning future research projects and addressing gaps
in knowledge.

Deighton, J. and Wolpert, M. (2009) Mental Health Outcome Measures for Children and Young People,
CAMHS Evidence-Based Practice Unit. Available at: www.corc.uk.net/resources/downloads/.
An overview of outcome measures, including those discussed in this chapter and many oth-
ers, is given in this report. The CAMHS (Child and Adolescent Mental Health Services) Outcome
Research Consortium (CORC) website (www.corc.uk.net) is an excellent resource for practitioner-
researchers interested in work with children and young people.

Hill, A., Cooper, M., Pybis, J., et al. (2011) Evaluation of the Welsh School-based Counselling Strategy.
Cardiff: Welsh Government Social Research.
This is a landmark piece of research evaluating the Welsh Assembly Government's School-based
Counselling Strategy, employed since 2008. The study incorporates outcome measurement,
interviews and surveys with key stakeholders such as counsellors and link teachers. The findings
showed reduction in psychological distress associated with counselling, with greater improve-
ments than in previous studies of UK school-based counselling services.
(Continued)
256 The Handbook of Counselling Children & Young People

(Continued)

Cooper, M. (2011) Meeting the demand for evidence-based practice. Therapy Today 22(4): 10-16.
McArthur, K. (2011) ‘RCTs: A personal experience’, Therapy Today 22 (7): 24-25.
Rogers, A., Maidman, J. and House, R. (2011) ‘The bad faith of “evidence-based practice”: Beyond
counsels of despair’, Therapy Today 22 (6): 26-29.
These three articles published recently in Therapy Today give an introduction to the debate sur-
rounding evidence-based practice and the use of randomised controlled trials (RCTs) in relational
counselling.

Online Resources

Counselling MindEd: http://counsellingminded.com, especially Module CMD 06: Using Measures.

Children and Young People’s improving Access to Psychological Therapies Programme (CYP IAPT):
www.cypiapt.org.
Griffiths, G. (2013) Helpful and Unhelpful Factors in School Based Counselling: Client’s Perspective.
Counselling MindEd Scoping Report. Available at: http://counsellingminded.com/wp-content/
uploads/2013/12/griffiths_MindEd_report.pdf.
 Part 3

Practice Issues
 \/
Law and Policy
Peter Jenkins

This chapter includes:

e A framework for categorising the legal rights held by children and young people
e Information on some ofthe key areas likely to cause anxiety, both to novice and more expe-
rienced therapists, their supervisors and managers
e Policy and law relating to children and young people, e.g. school-based counselling; mental
health services; and pre-trial therapy
e Key aspects ofthe law, such as the rights of children and parents, confidentiality, safeguarding,
information-sharing, contracting, record keeping and appearing in court

Introduction

This chapter starts by acknowledging the very real concerns held by many therapists
about the impact of law and policy on their therapeutic work with children and young
people. It is designed to be read in tandem with the accompanying chapter in this book
on ‘Ethics’ and outlines:

What Is the ‘Law’?

The term ‘law’ in this context, refers to all legal systems applying in the UK, with par-
ticular reference to England and Wales. Reference will also be made to the law applying
260 The Handbook of Counselling Children & Young People

to Scotland and Northern Ireland, where relevant. The law includes statutes, i.e. Acts of
Parliament, or devolved legislation, such as via the Welsh Government, common law
and case law. (For a more detailed discussion of these terms, see Jenkins, 2007.) ‘Policy’
refers to the statutory and voluntary provision of counselling services, including rel-
evant mental health services. This is based on legal requirements, codes of practice,
government reports, and established ‘custom and practice’ in relation to counselling
services.
The law can seem complex and intimidating at first sight. This chapter takes an
explicitly rights-based approach, as a way of making sense of the (sometimes conflict-
ing) legal pressures weighing upon the individual counsellor. A rights-based approach
considers the entitlement of children and young people to specific responses by
counsellors, social workers, parents, etc., regarding young people's rights to welfare,
participation and autonomy. A right is defined as ‘a claim to treatment which an indi-
vidual can make, by reason of law, code of practice or otherwise’ (Jenkins, 2013a: 5).
A child, in legal terms, is defined as a person under the age of 18, as per section 105,
Children Act 1989. While not a legal definition as such, it can also be useful to bear in
mind the distinction between children, of roughly primary school age, i.e. 6-11 years,
and young people of secondary school age, i.e. 11-18 years, respectively. These broad
age bands may carry differing levels of legal entitlement to autonomy, in terms of deci-
sion-making by younger people.

A Rights-Based Model of the Law Regarding Young People

The following approach categorises rights held by children and young people as being
of four types. In the first, children and young people are effectively denied a claim to
counselling or psychotherapeutic ‘treatment; either by the law, or as the effect of exist-
ing policy. In the second, children do hold rights within counselling and the wider
society, which are determined by adults in their best interests. In the third, children and
young people can exercise their rights to a say, in any decisions being made on their
behalf. In the fourth, children and young people can exercise their rights to autonomous
decision-making, independently of adult parents and care-takers.
Briefly, this model therefore suggests four types of rights for children and young
people with regard to counselling:

Level 1: Children have no rights to counselling;

Level 2: Children have rights to welfare and protection, decided by adults;

Level 3: Children have a right to participate in decisions made about them;

Level 4: Children have rights independent oftheir parents.

 Lawand Policy 261

Level 1: Children have no rights to counselling

One example of this would be the denial of young people’s rights to freely access information
on sexual orientation during the operation of ‘Section 28? i.e. from 1988-2003, forbidding
local authorities from actively promoting homosexuality as ‘a pretended family relationship.
Level 2: Children have rights to welfare and protection, decided by adults
Children have a right to be protected from ‘significant harm, under Section 47 of the
Children Act 1989, and under Articles 19 (protection from abuse) and 24 (protection
from sexual abuse) of the United Nations Convention on the Rights of the Child 1989.
Level 3: Children have a right to participate in decisions made about them
In deciding whether a child witness in a case of a criminal prosecution for alleged abuse
should have pre-trial therapy, ‘due consideration should be given to ascertaining the
wishes and feelings of the child, in a manner which is appropriate to the child’s age and
understanding’ (CPS, 2001: 16).

Level 4: Children have rights independent of their parents

Young people under the age of 16 of ‘sufficient understanding’ have a right to confiden-
tial medical treatment, without parental knowledge or consent, under the Gillick case
[1986], or via the Age of Legal Capacity Act 1991 in Scotland. This right can logically
be extended to include access to confidential counselling.
This model can be useful in helping therapists to distinguish between rights which
are driven more by adult perceptions, e.g. (Level 2: Protecting a child from harm), and
those which are more about the empowerment of young people (Level 4: Promoting
autonomy). A rights-based approach to the law and policy may have its weaknesses.
It may appear to over-emphasise the position of individuals, such as an entitlement to
confidentiality, at the expense of wider social considerations, e.g. the value of having
mandatory reporting systems for abuse. However, the advantage of this model is that it
permits a useful point of cross-over with ethics, as a decision-making aid, as the con-
cept of rights embraces both formal legal entitlements and the corresponding ethical
obligations for counsellors.

Ethical Dimensions of Legal Practice in Counselling Young People

Legally informed therapeutic work with children and young people clearly has an ethi-
cal dimension, just as ethical practice also has a legal aspect to it. However, there are
relatively few specific references to the law in the BACP Ethical Framework, in contrast
with the particular injunction that: “Working with young people requires specific ethi-
cal awareness and competence’ (2010b: 6).
262 The Handbook of Counselling Children & Young People

The key BACP statements regarding the law relate to:

e counsellor knowledge of the law and accountability to it;

e client rights of access to information;
e disclosure of information to third parties without client consent, under mandatory report-
ing requirements.

The BACP Ethical Framework (2010b) does not offer specific guidance regarding the
complexities of the law in relation to working safely with children and young people.
Nevertheless, it is clear that practitioners need, as with any client group, to be fully
aware of the law, understand it, and be accordingly accountable for their own profes-
sional practice.

Research on Law and Policy for Counselling Children

The limited research base on counsellors and the law tends to be drawn primarily from
practice-based evidence. Brown identified critical ethical dilemmas for generic coun-
sellors (n: 20), which broadly relate to issues of risk of harm/child protection issues,
information-sharing and record-keeping (2006: 101). Confidentiality emerges, unsur-
prisingly, as a key, but still problematic, issue in counselling young people in particular.
Confidentiality is highly valued by young people working with voluntary agencies
(LeSurf and Lynch, 1999; n: 42), and in schools (Cooper, 2009b). It is seen by young
people as being particularly important in relation to the provision of counselling and
treatment on sexual health issues (Carlisle et al., 2006; n: 18). This expectation appears
to have carried some weight in the judge's decision in the Axon case in 2006.

Policy and Law Relating to Counselling Children and Young People

The term ‘policy’ with regard to counselling for children and young people has two
main dimensions in this context. One refers to a hierarchy of sets of official guidance
to therapists, and the other to the actual provision of counselling services. It may be
tempting to see the law and policy as being completely ‘black and white’, with no room
for professional discretion over decision-making, but this is far from being entirely
the case. It is also important to understand that law and policy may be ‘out of synch
with each other. It may be the case that children and young people are entitled to cer-
tain rights according to the Jaw, but these are not afforded in practice by counselling

-ST LANCASHIRE
_ COLLEGE
=4RNER ZONE
 Lawand Policy 263

providers, due to the operation of a particular policy. One example of this would be
where young people under 16 in England and Wales are afforded autonomy rights via
the law, in terms of the Gillick case, but providers actually insist on evidence of paren-
tal consent, due to their policy. This would be an example of young people’s Level 4
autonomy rights being overridden by reference to paternalistic Level 2 rights (see sec-
tion above for the corresponding framework of children’s rights).

Law Relating to Counselling Children and Young People

The law, as suggested above, refers to all systems of law in the UK. The law varies
between different parts of the UK, so that child care law for England and Wales is deter-
mined by the Children Acts of 1989 and 2004, in Northern Ireland by the Children
(NI) Order 1995 SI 1995/755 (NI 2), and in Scotland by the Children (Scotland) Act
1995. Common legal principles may apply in each legal context, but, equally, there may
be significant differences. This discussion will cover mainly the law relating to England
and Wales, on the basis that much will also be common to the other jurisdictions in the
UK. However, therapists will need to check the detail of the law applying to their own
practice, as the law is subject to constant updating and change.
The term ‘law includes statutes, i.e. Acts of Parliament, such as the Data Protection
Act 1998. Statute law has an added significance for therapists, in that some therapists,
such as psychologists, are subject to statutory regulation, via formal bodies such as the
Health and Care Professions Council. In addition, some forms of counselling provision
are provided on a statutory basis, i.e. school counselling in Wales. This may help to
protect its resource base and impose a greater degree of public scrutiny of appropriate
professional standards.
The term ‘common law’ refers to law which is decided by judges on a custom and
practice basis over centuries, such as the law relating to confidentiality. Case law refers
to key legal decisions, such as the Gaskin and Gillick cases. In the first case, Graham
Gaskin, a young man formerly in care of Liverpool Social Services, sought to gain
access to his own social work file. He partially won his case at the European Court of
Human Rights at Strasbourg, opening the door for client access to social work, educa-
tion and medical files, a decade before the Data Protection Act 1998 came into force
(Gaskin v. UK (1988) [1990]; Jenkins, 2007: 140). In the second case, i.e. Gillick, it was
decided by the House of Lords that a young person under 16 could receive confidential
medical treatment without parental knowledge or consent, if judged to have ‘sufficient
understanding’ by a health practitioner. This decision was confirmed in the subsequent
Axon case in 2006.
264 The Handbook of Counselling Children & Young People

Table 17.1 Legal sources and their application to counselling practice.

Hierarchy of legal sources (in

descending order of importance) Examples potentially applying to counselling practice

Statute, i.e. Act of Parliament Children Act 1989; Data Protection Act 1998;
School Staridards and Organisation (Wales) Act 2013
Common Law Law relating to confidence/confidentiality
Case Law Gaskin case [1990]; Gillick [1986]; Axon [2006]
Statutory Codes of Practice Health and Care Professions Council Code (2012); Mental
Health Act Code (2008)
Statutory Guidance Working Together (2013) (England) and equivalent guidance
on child protection for Wales and Scotland; Practice Guidance
on pre-trial therapy for children (2001, 2002)
Government Reports Laming Report on Victoria Climbie Inquiry (2003)
Professional Codes of Ethics BACP Ethical Framework (2010)

Hierarchy of Legal Authority Relating to Counselling Practice

In terms of a hierarchy of law and policy, there are also statutory codes of practice,
which derive from specific Acts of Parliament. For example, the Code of Practice for
the Mental Health Act (MHA) 1983 sets out authoritative guidance for practitioners
working with adults and young people under 18, within the mental health services in
England and Wales (DoH, 2008a). The HCPC Code, Standards of Conduct, Performance
and Ethics (2012) set out a clear duty for its registrants, in relation to protecting chil-
dren from harm. Arguably, statutory codes such as the HCPC (for HCPC registrants
only) and MHA 1983 (for mental health practitioners) would carry significant weight
in a court of law, in determining a judge's perception of the appropriate professional
responses made by a therapist.
In terms of a hierarchy of guidance, the next level would include statutory guidance,
government circulars and statutory instruments. For counsellors, the key examples
here would include the relevant guidance on child protection and safeguarding, such
as Working Together (DfE, 2013), and its equivalent versions for Wales and Scotland. A
second example would include practice guidance on the provision of pre-trial therapy,
which is further discussed below (CPS, 2001). Other levels of this hierarchy of authority
and influence, regarding legal perspectives on good professional practice, could also
include influential reports, such as Lord Laming's report on failures of child protection
in the Victoria Climbie Inquiry (Laming, 2003) and, not least, professional codes of
ethics by therapist organisations (BACP, 2010b), setting out ethical principles, values
and minimum standards of therapist competence.
 Law and Policy 265

Policy and Provision of Counselling Services

This section covers three key areas of counselling provision for children and young
people, ice.:

e school-based counselling
¢ counselling as part of mental health services
¢ pre-trial therapy (i.e. counselling for a child witness prior to a criminal trial)

School-Based Counselling

Historically, counselling has mainly tended to be provided on a voluntary, non-statutory

basis within the UK, by a wide range of providers. This has included provision by vol-
untary or third-sector agencies (Street, 2013) and by private and independent therapists.
Counselling has been long established within the Further and Higher Education sectors as
an element of pastoral care, for students moving from adolescence into young adulthood.
School counselling within secondary schools saw a decline from a peak of influence in
the 1960s, but has since undergone a resurgence, with an estimated 80 per cent of second-
ary schools in England now providing counselling for pupils, and 100 per cent in Wales
(Hanley et al., 2012). Secondary school counselling is now a statutory requirement in

Table 17.2 School-based counselling: Comparison of current and potential future

patterns of counselling practice (adapted from Jenkins and Polat, 2006: 11).

Current pattern Potential future pattern

Child-centred orientation. Family-centred orientation.

Model of Confidentiality Exclusive model of Inclusive model of confidentiality.

confidentiality.

Limited sharing of client Routine sharing of client

information. information.

Role-based professional Task-based professional boundaries.

boundaries.
Professional Orientation Individual focus of therapy. Systemic and community focus of
therapy.
Status as individual practitioner. Member of inter-disciplinary team.
Relationship to Other Loose integration with other High levels of integration with other
Professions support services. support services.
266 The Handbook of Counselling Children & Young People

Wales, under Section 92, School Standards and Organisation (Wales) Act 2013. Increasing
numbers of primary schools also provide counselling for children.
The rapid expansion of school-based counselling has made this provision available to
a growing number of young clients, in a non-stigmatising and accessible format (Cooper,
2013). However, it has also brought with it some major challenges to the counselling
profession, particularly that of integrating therapy within schools, as highly complex,
bureaucratic organisations, with their own distinct ethos and culture. In addition, it
could be argued, perhaps controversially, that the traditional model of child-focused
counselling has been strongly challenged by the safeguarding agenda (see below). This
may have led to pressures for the adoption of a more multi-disciplinary, team-based
approach, with different expectations about confidentiality and information-sharing
(see Table 17.2).
Not least, in terms of policy, the growth of school-based counselling has raised key
questions about its relationship towards other, related forms of provision, such as
mental health services.

Counselling as Part of Mental Health Services

Counselling can also be provided as part of mental health services. The Mental Health
Act 1983 Code of Practice for England shows strong signs of influence by the Gillick
case. It confirms the rights of young people under 16 to confidentiality, if of suffi-
cient understanding (DoH, 2008a). Provision of mental health services for children
and young people is determined within England and Wales by the National Service
Framework, setting out relevant standards (DfE/DoH, 2004). This has identified prob-
lem areas, such as the relative lack of provision for 16-17-year-olds, the perceived gap
between adolescent and adult services, and the inappropriate placement of some ado-
lescents on adult psychiatric wards. Other weaknesses include problems transferring
between adolescent and adult services, and the lack of provision for self-referral by
young people, in order to access mental health services.
Counselling provision within mental health services within England is provided
via Child and Adolescent Mental Health Services (CAMHS). This operates on a four-
tiered level of service:

Tier 1: Primary level of service, such as initial assessment and referral by GPs;

Tier 2: More specialised provision, by child psychologists and some school counsellors:

Tier 3: Specialist provision via multi-disciplinary teams, such as CAMHS;

Tier4: Highly specialist out-patient and in-patient services for severe mental health
problems, such as eating disorders.
 Lawand Policy 267

Mental health services provide medication and psychological therapy. Both are gov-
erned by reference to NICE guidance, for example regarding the use of anti-depressants
for under-18s. It also applies in relation to evidence-based therapies, such as cognitive-
behavioural therapy (CBT), for a wide range of presenting problems, such as anxiety,
depression and self-harm.
Access to CAMHS is governed by referral gateways, such as via GPs, school coun-
sellors and social workers. Increasingly, CAMHS services are mapped onto the tiered
system used by Children and Young People Improving Access to Psychological Therapies
Programme (CYP IAPT) (Spong et al., 2013). This was initially aimed primarily at adults
and has now been extended to include children and young people (see Table 17.3).
Counselling services within CYP IAPT are closely evaluated via a battery of outcome
measures. CYP IAPT services for children and young people may provide a wider range

Table 17.3 Stepped care model for the CYP-IAPT service (Bala et al., 2011: 24).

Stage/step Services Interventions available

Step 5 CAMHS psychiatrist . Specialist services (Tier 4 CAMHS)

Inpatient CAMHS services
Step 4 Core CAMHS team Secondary care services (Tier 3 CAMHS)
Step 3: High Core CAMHS team Systemic, narrative and solution-focused
intensity CAMHS outreach team (Children in therapies
interventions Need/Looked After Children) CBT
Primary Care Children and Young Face-to-face counselling
Persons worker team Family counselling
Bereavement service Bereavement counselling
Play therapy
Psychology
Specialist parenting groups
Psycho-educational and psychotherapeutic
groups
Signposting/assessment/step up/step down
Step 2: Low Streetwise Guided self-help based on CBT
intensity Action for Children Parenting groups
interventions Targeted Adolescent Mental Health Behavioural activation
Services Team Structured physical activity
Psychological well-being Computerised cognitive-behavioural therapy
practitioners 16-19 (CCBT)
Bibliotherapy
Psycho-educational workshops and groups
Signposting/assessment/step up/step down

Step 1: GP Watchful waiting

Primary care Children’s health services Advice and information
Education Local parenting groups
Social care services
268 The Handbook of Counselling Children & Young People

of types of therapy than their adult equivalent. However, cognitive-behavioural therapy

may hold a key position in terms of recommended treatment, given its privileged,
evidence-based status within NICE guidelines.
The above model is based on the work of Bury NHS Primary Care Trust. It is included
simply as an illustration of CYP IAPT provision for children and young people, rather
than claiming to be either representative, or prescriptive. The CYP IAPT model in
general may well be significant for the future of counselling provision for children, in
adopting a systemic, tiered approach, using a wide range of therapeutic interventions,
for targeted treatment and therapy for assessed psychological difficulties, which are
then subject to comprehensive outcome measurement.

Pre-Trial Therapy

Where a child or young person is potentially a witness in a criminal trial, for exam-
ple, as the victim of alleged abuse, therapy is governed by practice guidance issued
by the Crown Prosecution Service and other agencies (CPS, 2001). This sets out very
clear and specific parameters for the provision of counselling. Any pre-trial counsel-
ling must be provided in close liaison with the Crown Prosecution Service (CPS) and
avoid rehearsing evidence, or revisiting the original alleged abuse. This is in order to
pre-empt future claims by the defence solicitors that the child’s evidence has been ‘con-
taminated’ by the therapy, or that the child has been ‘coached’ by the therapist. The
counsellor is required to keep careful records of therapy, which are accessible to the
CPS. Any fresh disclosures of abuse, or material changes to the child’s evidence, must
be reported to the CPS. The guidance lists certain types of therapy, including hypno
therapy, psychodrama and group therapy, amongst others, which are identified as
presenting particular problems for the child later giving evidence in court. Anecdotal
evidence suggests that some children are still being actively discouraged by the authori-
ties from attending counselling before the criminal trial, despite this advice running
directly counter to the ethos of this guidance. Pre-trial therapy for child witnesses and
victims of abuse has received relatively little research attention, despite its prominence
as a complex and significant issue for many practitioners and clients. Plotnikoff and
Woolfson (2009; n: 182) found continuing delays in child abuse cases going to court,
and high levels of anxiety amongst young witnesses.

Key Aspects of the Law Relating to Counselling Children

There are a number of key aspects of the law relating to counselling children and young
people. These include:
 Lawand Policy 269

rights of children and parents

confidentiality and privacy
safeguarding and child protection
information-sharing with other professionals
contracts and contracting
record-keeping and data protection
appearing in court

Rights of Children and Parents

Children and young people under the age of 18 in the UK have extensive rights to the
provision of counselling (Level 2 rights), to participation in decisions (Level 3 rights)
and to autonomy (Level 4 rights). (For a detailed outline of this framework, see Jenkins,
2013a; for its application to counselling, see Jenkins, 2013b, and Daniels and Jenkins,
2010.) The rights of parents were substantially recast by the Children Act 1989, to
assume the much narrower form of ‘parental responsibility. This legal power is not
limited to biological parents, but can be legally acquired by other significant figures in
a child’s life, such as a grandparent. The notion of ‘parental rights’ has been radically
reframed and slimmed down, to now include essentially, parental duties to provide for,
educate and protect children (see Daniels and Jenkins, 2010: 18). Counsellors should
therefore be wary of accepting at face value any claim to ‘parental rights’ as affording a
parent the authority to intervene into the counselling space where the client is a child
or young person.

Confidentiality and Privacy

Young people aged 16 to 17 years have the same entitlement to confidentiality as would
an adult, under Section 8, Family Law Reform Act 1969. Under the age of 16, young
people in England and Wales, with ‘sufficient understanding; are deemed capable of
consenting to medical treatment by a health practitioner, following the Gillick case.
Confidentiality is an essential pre-condition for exercising such consent, according to
the Axon case in 2006. This confirmed that ‘Gillick remains good law (Axon [2006] at
24). Following the principles set out in Gillick, it follows that parental consent is, there-
fore, not a legal requirement for counselling a young person under 16 with ‘sufficient
understanding:
Children of any age also have the right to respect for their private and family life,
under Article 8 of the Human Rights Act 1998. In 2003, Naomi Campbell won a key
legal case and was awarded damages for breach of privacy, when the Daily Mirror
270 The Handbook of Counselling Children & Young People

published photos of her leaving a meeting of Narcotics Anonymous. Following the

Campbell case [2004], it could be argued that this right of privacy extends to the very
fact of actually attending counselling. This may be true even for those primary school-
age children, who may be considered as too young to qualify for confidentiality under
the Gillick criteria (Daniels and Jenkins, 2010: 135).

Safeguarding and Child Protection

There is now an extensive safeguarding and child protection agenda in place, designed
to protect children under 18 from abuse. Child abuse is defined as ‘significant harm,
under Section 47 of the Children Act 1989 for England and Wales. Children and young
people within these jurisdictions are protected via the Children Acts of 1989 and 2004,
the safeguarding provisions of the Education Act 2002 and the vetting provisions of the
Safeguarding Vulnerable Groups Act 2006 and Protection of Freedoms Act 2012. These
are then set out in detail, at an operational level, by statutory guidance, such as Working
Together (DfE, 2013) and the equivalent guidance applying variously to Scotland, Wales
and Northern Ireland.
There is, however, a widening gap between the formal Jaw on this issue and the
policy of many agencies, with regard to the reporting of alleged abuse. It is quite clear
that ‘there is no mandatory reporting law in England and Wales, according to Hoyano
and Keenan (2007: 444). However, many agencies operate on the basis of an obliga-
tory abuse reporting policy, which is imposed as a term of the counsellor’s contract of
employment. This can clearly be justified by appeals to the concept of social justice
and by being demonstrably ‘in the public interest: Nevertheless, it can also raise acute
ethical and professional dilemmas for counsellors working with mid- to late-age-range
teenagers. Such clients may be making highly conflicted disclosures of abuse, but might
not be perceived by the counsellor as being at immediate risk of exposure to current or
continuing significant harm.
This issue of mandatory reporting of child abuse has been the subject of sev-
eral research reports relevant to current debates about safeguarding. Goldman and
Padayachi (2005) found a tendency for school counsellors in Australia (n: 122) to
under-report their suspicions of child sexual abuse, possibly due to their lack of confi-
dence in accurately identifying symptoms of abuse. Bryant and Baldwin (2010) found
a similar reticence regarding reporting abuse amongst school counsellors in the US
(n: 193), which has a similar system of mandatory reporting. These research findings
would suggest that counsellors’ abuse reporting practice relies on more than a simple
legal requirement to do so, and is, in part, mediated by professionals’ own perceptions
and practices.
 Law and Policy 271

Information-Sharing with Other Professionals

In legal terms, information-sharing with other professionals can be justified by obtain-

ing the consent of the child or young person. It can also be carried out without consent,
if it can be justified as being ‘in the public interest’, ie. in preventing significant harm
to the child or young person concerned. On information-sharing practice within safe-
guarding, Bunting et al. (2010) provide an extensive literature review. Brown’s research
(2006) has identified some of the role-strain experienced by counsellors between, on
the one hand, respecting client confidentiality and, on the other, becoming involved
in information-sharing with other professionals. Cromarty and Richards (2009) found
less evidence of this difficulty amongst school counsellors (n: 16). However, they
identified a preference amongst counsellors for sharing information with trusted indi-
viduals, rather than in a group setting, where there was less control over its subsequent
use. Rees et al. (n: 24) found similar concerns about retaining control over information
amongst young people, in making disclosures of abuse to social workers. ‘For young
people, the relationship with social work practitioners was central to disclosure and
protection (2010: 52).

Contracts and Contracting

In England and Wales, young people under 18 (under 16 in Scotland) are not usually
deemed capable of entering into a legally binding contract, with certain rare exceptions
(Mitchels and Bond, 2010: 64). Where counselling is being directly paid for, then the
contract would often be between the counsellor and the parent concerned. The terms of
the contract need to specify the limits to confidentiality applying to the therapeutic work
and any restrictions on the nature of the counsellor’s reporting back to the parent(s) of
the process and content of therapy. In other contexts, it may be that the counsellor is
carrying out their work under contract to an agency, such as children’s services. Again,
the specific terms of the contract may include provisions for returning completed case
files to the agency purchasing the service, and an obligation to report any disclosures
of abuse made during therapy.
Mitchels and Bond (2010: 65-6) discuss the capacity of children and young people
to make ‘therapeutic contracts, according to their age, understanding and legal juris-
diction. Where these are not properly legally binding contracts, these might be more
accurately described as ‘consent agreements, or even as ‘working charters. This is
precisely to avoid any potential confusion over their legal status. Such an agreement
can set out clearly practical arrangements for therapeutic work, any limitations to
272 The Handbook of Counselling Children & Young People

confidentiality, data protection requirements and provision for client complaint, in

the event of dissatisfaction

Record-Keeping and Data Protection

Record-keeping in counselling children and young people is covered by the somewhat

complex guidance derived from the Data Protection Act 1998 (ICO, 2009). The law
essentially parallels provision for record-keeping for adult clients, but with significant
differences relating to access to records by younger clients (see Jenkins, 2007). Data
protection requirements cover all processing of personal data, i.e. client recording, in
electronic/computerised, including audio, video and digital recording, and manual/
handwritten formats. Records must be accurate, relevant, not excessive for their pur-
pose and kept no longer than necessary. Health, social work and education records
comprise a special sub-set of client records. This is based on the successful case brought
by Graham Gaskin for access to his own social work file in 1988 (Gaskin v. UK (1988)).
Counselling records in health, social work and education contexts will therefore com-
prise a sub-set of the child’s corresponding health, social work or education file, with
certain specific implications for school counsellors.
Record-keeping in therapeutic work with children may be governed by agency poli-
cies, regarding their content and time-limits. Generally, as with adult clients, the Data
Protection Act (DPA) 1998 has seen a marked shift away from the keeping of
therapist- and process-focused recording, towards much briefer, primarily factual,
records. Records of therapy with pre-trial child witnesses need to follow this approach
and are, in principle, accessible to the Crown Prosecution Service (2001). Children
and young people have rights as data subjects to access their own files. There are some
limitations to access, based on the contextual setting of therapy and the nature of the
record kept (Jenkins, 2007). A child under 16 can exercise their rights under the Act, if
possessing ‘a general understanding of what it means to exercise that right’ (s. 66, DPA
1998), which is assumed to apply from the age of 12. Conflicts can arise when parents
seek to access health, education and counselling records, independently of the child, as
may happen in contested cases concerning divorce, or medical treatment.

Appearing in Court

All counselling records are potentially accessible to the courts via a court order.
Counsellors do not possess legal privilege in the UK, with the limited exception of mar-
ital relationship counsellors (Jenkins, 2007: 105). Equally, a counsellor may be called
 Lawand Policy 273

upon to write a report for the court, as either a professional witness, or as an expert
witness. The tasks of report writing, or appearing as an expert witness, for the court
require substantial professional experience and, ideally, specialist training. Where ther-
apists are asked to provide court reports, these are often related to the assessment of
attachment, parenting, child development, trauma, or child abuse. This may be in the
context of proceedings connected with divorce, separation, parental contact, domestic
violence, adoption, or child care proceedings.
Counsellors called to court can obtain expert legal advice from their employer, if
applicable, and from their professional indemnity insurance society, or psychologists’
protection society. Counsellors employed by large organisations may have an advan-
tage over colleagues in private practice, in having easier access to the legal resources
of the relevant employing Local Education Authority or NHS Trust. Legal and profes-
sional advice can also be obtained from professional associations, such as BACP, UKCP,
BABCP, or BPS, as appropriate. Counsellors providing pre-trial therapy for child wit-
nesses in alleged abuse cases need to be particularly mindful of the practice guidance
governing therapy in these circumstances and to follow it closely (CPS, 2001). Advice
for counsellors on appearing in court is aptly summarised as ‘Dress up, stand up, speak
up and shut up!’ More generic suggestions for giving evidence in court are outlined in
Jenkins (2007: 52-73).

a ee
Case Study Parveen
Parveen worked as a counsellor in a secondary school run by the local authority, and developed a
particularly close therapeutic alliance with Simon, aged 12 years, who came from a fairly chaotic
family background. There was some evidence of poor parenting by his mother, a single parent
with multiple domestic and housing problems. Parveen met with Simon on a regular basis, with no
missed sessions. She was actively supported in this work by the head teacher, who saw the counsel-
ling as enabling Simon to engage as well as he could with his studies, as an ‘oasis’ in an otherwise
stormy life. Simon's social worker was also highly appreciative of this therapeutic work, but respect-
ful towards the ongoing therapy as a ‘private space’ while also trying to support his mother with her
daily struggles.
The situation changed drastically when Simon's case was taken over by a new social worker, with
avery different attitude towards the counselling. The new social worker instructed Parveen to attend
a ‘CAF’ (Common Assessment Framework) meeting, where she would be expected to update the
professionals attending on the fine detail of what Simon was discussing in therapy. Parveen was
concerned at this, as Simon was not prepared for the detail of the counselling session to be shared in

(Continued)
=)
 274 The Handbook of Counselling Children & Young People

ER
(Continued)

this way. The social worker’s view was that the school counsellor was now part of a multi-disciplinary
team, and that Parveen was duty-bound to share all relevant information about Simon, as a ‘child in
need’, under the Working Together guidelines. Parveen’s referring to the BACP Ethical Framework was
dismissed as being ‘just a code of ethics, even though the head teacher supported Parveen in her
defence of client confidentiality. Parveen was informed in no uncertain terms by the social worker
that, if she failed to attend the meeting and share all relevant information, Simon would be referred
to CAMHS, with the result that the school counselling would cease forthwith.
Ly

Summary

e Law and policy may be perceived by practitioners as being highly complex, but they provide a
framework for working therapeutically with children and young people in the UK
e The legal framework consists of a hierarchy of law, ranging from statute, case law, codes of
practice, to statutory guidance, official reports and voluntary codes of ethics
e Policy overlaps with this legal framework, in setting out the requirements for counselling pro-
vision, e.g. within mental health services, YP IAPT and NICE guidelines
¢ Much counselling provision, for example in schools or in voluntary organisations, currently
sits outside these statutory frameworks, but is heavily influenced in practice by statutory
provision, such as in CAMHS, or by the safeguarding and child protection agendas
e Arights-based model offers a way of grasping the rights of young people, and protecting the
‘confidential space’ in which counsellors do their valuable work

Reflective Questions

1 What are the rights ofthe child in the situation discussed in the
case study?

Simon has a number of rights in this situation. He has a right:

e toa say in decisions being made about him, under Article 12 of the UN Convention on the
Rights of the Child (UNICEF, 1989)
e to confidentiality, if of ‘sufficient understanding, under the Gillick case [1 986], confirmed
by Axon [2006]
 Lawand Policy 275

e to therapeutic privacy, under the Campbell case [2004]

e to services from the local authority, if deemed to be a ‘child in need’ under Section 17,
Children Act 1989

2 What is the legal situation for the counsellor in this situation?

The school counsellor’s legal position is influenced by safeguarding policy and by

employment law, i.e.:

e the local authority has a duty to safeguard and promote the welfare of children, under
Section 175, Education Act 2002
e the local authority is required to cooperate with social services in providing services for
‘children in need’, under the Children Acts 1989 and 2004
e the counsellor is obliged to comply with school and local authority policy with regard to
attending safeguarding meetings, under the terms of her contract of employment

3 What are the options available to the counsellor in this

situation?

The counsellor has a number of options here, i.e.:

e seek professional guidance from the BACP Ethical Framework and the BACP Information Office
e clarify her professional and therapeutic options, through supervision with a suitable qual-
ified counsellor with experience in working with children and young people
e obtain expert legal advice from her professional indemnity insurance provider, or profes-
sional protection society
e review school policy on confidentiality and information-sharing with the head teacher, in
order to protect school counselling confidentiality as far as possible

¢ ¢
i] Learning Activities
i
i 1. Check online for the latest version of Working Together (DfE, 2013) or its equivalent and
i
read the sections on:
4
i © information-sharing
| o achildin need
’ © safeguarding
i
i (Continued)
x ¢
276 The Handbook of Counselling Children & Young People

ee en a Ne ee,
é
i} (Continued)

y 2. Check the safeguarding policy of your own counselling agency, and how it might apply
i in this situation
1 3. Construct a possible solution which might offer a way forward in this complex situation
i and discuss it with your tutor, supervisor or line manager
SSeS eee Be Oe o eoe S eo ee
¢

Further Reading

Daniels, D. and Jenkins, P. (2010) Therapy with Children: Children’s Rights, Confidentiality and the
Law. 2nd edn. London: SAGE.
Jenkins, P. (2011) A Confidential Space: Ethical Considerations When Counselling Children and Young
People. DVD: University of Wales. See: http://hss.newport.ac.uk or https://sites.google.com/
site/counsellingdvds/a-confidential-space.
Jenkins, P. (2013) Children’s and Young Persons’ Rights to Counselling. 2nd edn. Brighton: Pavilion.

Online Resources

See Counselling Mind-Ed session on ‘Applying the Law’.

Counselling MindEd: http://counsellingminded.com/.

Legal Cases

Axon, R (on the application of) v. Secretary of State for Health and Anor [2006] EWHC 37 (Admin).
Campbell v. MGN Ltd [2004] UKHL 22
Gaskin v. UK ECHR 2/1988/146/200, [1990] 1 FLR 167.
Gillick v. West Norfolk AHA [1985] 3 All ER 402; [1986] AC 112.
 Ethics
Peter Jenkins

This chapter includes:

| ERTL I STEELE SEEN LOIS TIO EE SPALL SEBOCEBEG TSE IEEEEEEEBES IS PIIISLED IESE ES TEINS EIDE EMRSOEE EERE ES,

e An exploration of some of the different approaches to ethics within counselling and psycho-
therapy, and the particular issues of concern with regard to counselling younger and more
vulnerable clients
e The value of adopting a rights-based approach to addressing ethical dilemmas in therapy with
children and young people, and an exploration of anumber of key areas of concern to thera-
pists, including contracting, and undertaking research with children
e A discussion of recent research evidence on how practitioners actually work in practice with
some of the key issues confronting them in their day-to-day practice with children and young
people

This chapter is designed to be read in conjunction with Chapter 17,‘Law and Policy’ in this volume.

Counsellors often tend to see the subject of ethics as a topic which is dry and academic,
or as being worthy, but slightly dull, or even as an ‘add-on’ to the more central task of
actually working in therapy with children and young people. This is a real misreading
of the importance and value of ethics, which is defined as ‘a generic term for under-
standing and examining the moral life’ (Beauchamp and Childress, 2008: 1). Ethics
is concerned with addressing, and attempting to find answers to, key therapeutic
dilemmas such as:
278 The Handbook of Counselling Children & Young People

e achild’s parents insisting on knowing what is said in the therapy session;

e anagency requiring al/ under-age sexual activity to be reported as a risk factor;
e defining the age at which a child becomes self-determining and acquires a right to
greater autonomy.

Ethical Practice and Codes of Ethics

The counselling profession attempts to support, monitor and reinforce ethical prac-
tice amongst its members, by providing codes of ethics, or ethical frameworks, for
decision-making, and by implementing complaints procedures, in order to offer
redress to aggrieved parties. Codes of ethics are, in turn, not set in stone, but change
over time. They are influenced by changing professional perceptions, broadening
experience, key cases or complaints, and by the changing legal and policy context.
Codes attempt to embody the current professional wisdom of the time, but they can-
not realistically seek to answer every issue confronting a counsellor or supervisor.
Instead, codes offer a framework for responding to both everyday and more complex
and unusual challenges to therapeutic practice.
Professional approaches to ethics also vary between professional associations and
change over time. A key moment in the development of the counselling and psychother-
apy profession was marked by the decisive shift by the British Association for Counselling
and Psychotherapy, from the former Code of Ethics (1998), to the Ethical Framework for
Good Practice in Counselling and Psychotherapy, in 2002 (BACP, 2010b). It is often not
fully appreciated that codes or frameworks speak with different tones or authority, in set-
ting out, for example, what counsellors may do (or may not do), and what they must do.
These tones, or requirements, can be described as including the following:

e advisory: Psychologists ‘should practice within the boundaries of their competence’ (BPS,
2011 [2009]: 16)
e supportive: ‘Practitioners are strongly encouraged to ensure that their work is adequately
covered by insurance’ (BACP, 2010b: 7)
e prescriptive:‘You must keep accurate records’ (HCPC, 2010: 3)

The BACP Ethical Framework contains a variety of different authoritative tones, but
marks a distinct shift away from the earlier binding set of prescriptions. It recognises
that counsellors need a more flexible set of ethical guides, where there are competing
claims for action, and there is not necessarily one single, right answer to a pressing
ethical dilemma.
Within philosophy, there is a wide range of different approaches to the study of ethics.
These different approaches include the following:
 Ethics 279

¢ deontological, i.e. rule following, prescriptive: ‘You must not break client confidentiality’
¢ teleological, i.e. based on achieving a positive outcome: ‘You may decide to break confi-
dentiality, in order to avert client suicide’
e rights-based, i.e. based on an active appreciation of the rights of all parties involved, e.g.
‘You need to balance the child's right to privacy, versus their right to protection from harm’

The approach taken in this chapter follows an explicitly rights-based model, while
acknowledging the valuable contribution of both rule-following and outcomes-based
approaches. It also needs to be borne in mind that the practical application of ethics in
counselling does not solely revolve around the ethical stance adopted by the counsellor.
It is increasingly clear that children and young people also bring their own expectations
and a strong sense of ethics and fairness to therapy, which can become a key factor in
the unfolding of the therapeutic work (Jenkins, 2010).

Ethical Approaches to Work with Children and Young People

Discussion of ethical approaches to work with children tends to have a distinct nature,
marking it apart from more generic discussions about ethics in counselling with adult
clients. This is so for a number of reasons. The terms ‘children’ and ‘young people’ cover
a wide range of age groups and situations; the ‘child’ in question may be aged 17 (using
the term ‘child’ in a strictly legal sense); or the ‘young person’ may be aged 12 or 13.
The terms children and young person/young people are used here to denote persons of
roughly primary school age, i.e. 6-11 years, or secondary school age, i.e. 11-18 years,
respectively. This follows a broad distinction, between children, who are assumed not
to be mature enough to make decisions for their own care, and young people, who may
have developed sufficient maturity to do so. However, this broad distinction is no more
than a very rough guide, as there will emerge situations where these categories are not
particularly useful in guiding ethical decision-making by the counsellor.
Counselling work with children and young people is also considered to be a distinct
field in terms of ethics, because of the child or young person’s developmental, physi-
cal and emotional vulnerability. The long-term adverse effects of child abuse, trauma,
bullying and emotional abuse are by now well-established. Children and young people
may also be more subject to manipulation by powerful and respected adult author-
ity figures, perhaps lacking an adult's wider experience of relationships, on which to
judge a counsellor’s influence. By definition, children and young people are also heav-
ily dependent upon adults for their everyday care, protection and control, whether in
a family, hospital, residential care home, or in a custodial setting. It is also probably
much more likely that counselling will involve potential contact by the counsellor with
adult third parties, who take an active interest in the process and outcomes of therapy,
280 The Handbook of Counselling Children & Young People

whether as parents, foster-parents, social workers, teachers, or judges, than would nor-
mally be the case with an adult client. This vulnerability to harm, and corresponding
dependence upon adult care-takers, is recognised by specific provision for children and
young people under the law, which then becomes a further crucial element, in terms of
ethical decision-making by counsellors.
There is limited counselling-based research on how counsellors work with ethi-
cal dilemmas in their practice, mostly drawn from practice-based evidence, such as
work by Brown (n: 20), in exploring the uncertainties experienced by counsellors in
confronting issues which relate to young people, such as child protection (2006: 102).
Research on the nature of the therapeutic alliance in working with young people has
emphasised the key role of the therapeutic alliance, and within this, confidentiality
as a central component of the therapeutic environment (Everall and Paulson, 2002).
This latter small-scale survey (n: 18), carried out in Canada, found that many young
clients did not grasp that the context of therapy radically influenced the limits of con-
fidentiality, hence underlining the need for careful initial contracting to set out the
limits of confidentiality. This finding is echoed by LeSurf and Lynch, in their research
with young clients of a counselling agency (n: 42). They found with young people that
‘their desire for confidentiality related not so much to concerns for privacy, but to a
wish to retain control over the material which they disclosed’ (1999: 237). A study
by Finkenauer et al. (2002; n: 227) found that the provision of client confidentiality,
in essence the keeping of secrets from parents and authoritative adults, had an addi-
tional and unexpected developmental value, in promoting a stronger sense of autonomy
amongst young people.

BACP Ethical Framework

The BACP Ethical Framework (2010b) will be taken as the main reference point for dis-
cussion, while acknowledging that there are other, equally valid, ethical codes available
for practitioners belonging to other professional associations. The Ethical Framework
refers to values, ethical principles and (often overlooked) the personal qualities of thera-
pists, as components of informed ethical decision-making. These separate elements
amount to a kind of ‘scaffolding; which supports and empowers counsellors, in making
often difficult decisions. The Ethical Framework identifies a number of key areas for
special attention in therapeutic work with children and young people (BACP, 2010b: 6):

° specific ethical awareness in therapeutic work with children and young people;
¢ competence in therapeutic work with children and young people;
e assessing the balance between a child or young person's dependence on adults and carers
and their progressive development towards acting independently;
 Ethics 281

e the child or young person's capacity to give consent independently of adults with parental
responsibilities;
e the management ofany confidences disclosed by the child or young person.

These areas, which are identified as especially sensitive, or even problematic, could eas-
ily occupy a special ethical framework simply for work with children and young people.
The complexity of devising a set of ethics for work with children and young people is
further recognised in discussion of the possible constraints to a key ethical principle,
i.e. that of autonomy. The Ethical Framework sets out key principles, including respect
for autonomy, i.e. ‘a client’s capacity to be self-directing within therapy and all aspects
of life’ (2010b: 3). It notes, however:

An obligation to act in the best interests of the client may become paramount when
working with clients whose capacity for autonomy is diminished because of immatu-
rity, lack of understanding, extreme distress, serious disturbance or other significant
personal constraints. (BACP, 2010b: 3)

As with adult clients, the counsellor may be working to promote the client’s developing
sense of autonomy, or ability to make decisions for themselves. However, this quality
of autonomy may be radically compromised by the immaturity of a child, or young
person, in the role of client. For example, a 10-year-old client may be exposed to, or
encouraged to drink, alcohol in their home by older peers, or by parents. The child’s
autonomy, in choosing to experiment in this way, may be in conflict with their lack of
maturity in making such a decision, which then places them at risk of harm.
Regard for client autonomy, in the case of children and young people, may be framed by
respect for ‘their progressive development towards acting independently’ as above (BACP,
2010b: 6), or by the related concept of the ‘evolving capacities of the child, drawn from the
UN Convention on the Rights of the Child 1989 (UNICEF, 1989: 5). However, in some
cases, a child or young person’s assumed rights to autonomy may be assessed to be signifi-
cantly impaired, or even malignant in nature. This process can be observed in the case of a
sexually exploited young person, still under the age of consent, mistakenly being deemed
by social workers, or police, to be evidently making ‘their own choices’ to become involved
in ‘consensual sexual activity’ with adult males (RBCSB, 2012: 9).

A Rights-Based Approach to Therapy with Children and Young

People

The field of ethics in therapy with children and young people is often seen as being
hugely complex and risky, not least for practitioners. The advantage of a rights-based
282 The Handbook of Counselling Children & Young People

approach is that it offers a way of categorising a wide range of conflicting material, of

identifying key underlying ethical principles in decision-making and of linking ethical
choices with the often closely-related legal framework underpinning such decisions.
This framework is developed in more detail elsewhere (Daniels and Jenkins, 2010;
Jenkins, 2011).
Within this model, a right is defined as ‘a claim to treatment which an individual
can make, by reason of law, code of practice or otherwise’ (Jenkins, 2013a: 5). Thus a
child may have a right to privacy, regarding accessing therapy, which is both an ethical
imperative for the counsellor and agency, and also, arguably, a legal right under the
Human Rights Act 1998. In some cases, a child may require the proper support of an
adult, in order to claim such a right, whether in the role of advocate, solicitor, or social
worker.
Briefly, the model suggests four types of rights for children and young people with
regard to counselling:

Level 1: Children have no rights to counselling;

Level 2: Children have rights to welfare andprotection, decided by adults;

Level 3: Children have a right to participate in decisions made about them;

Level 4: Children have rights independent oftheir parents.

Level 1: Children have no rights to counselling

This category relates to children effectively being denied access to counselling, or
having their access severely and unjustifiably constrained. Examples would include a
requirement for parental consent to access counselling provided in secondary schools;
proposals for the mandatory reporting of under-age sexual activity by counsellors in
sexual health clinics; constraints and limitations on the discussion of sexuality in state
schools; age limitations on referrals to counselling services in primary care; and refusal
of self-referrals by young people to mental health services.
Level 2: Children have rights to welfare and protection, decided by adults
Within this category, children and young people have rights to the provision of coun-
selling, for example, for gay and lesbian young people in care, and for children with
a disability, under Guidance and Regulations for the Children Act 1989; for children
and young people in schools in Wales; for children who have broken the law, under the
UN Convention; and to access pre-trial therapy, when awaiting court action as a wit-
ness in the case of alleged abuse. In addition, children and young people have a right
to be protected from significant harm, including physical and sexual abuse, under the
Children Act 1989.
 Ethics 283

Level 3: Children have a right to participate in decisions made about them

Under the Children Act 1989, children in care, or those appearing in civil court, have
rights to be consulted about decisions being made about them, depending on their age
and level of understanding. This right is extended to all children by Article 12 of the
UN Convention, ratified by the UK government in 1991. This right would include an
entitlement to be actively consulted in the contracting process within therapy, for
example, regarding the proposed limits to confidentiality; it should also include young
people being consulted about school policies on parental permission for accessing
counselling, and on proposed closures of youth counselling services by local authorities.
Level 4: Children have rights independent of their parents
Children and young people also hold substantial rights in relation to counselling,
which are independent of parents or adult care-takers. Young people aged 16 to 17 have
rights to consent and confidentiality equivalent to adults. Young people under 16 have
rights to counselling confidentiality and to consent to medical treatment, if of ‘suffi-
cient understanding, in the view of the relevant medical practitioner, and, arguably, of
the counsellor. Some of these rights are non-age dependent, in that the child has rights
to confidentiality of personal data, and to privacy, regardless of age.
In ethical terms, these sets of rights correspond to key ethical principles. Level 1 con-
cerns the denial of rights to children and young people, presumably on the basis of
age, thereby contradicting the ethical principle of justice. Level 2 rights relate to classic
welfare rights, including the ethical principles of beneficence, or welfare, and non-
maleficence, namely the avoidance of harm to the client. Level 3 rights directly express
the broader social value of the child’s participation in decision-making, which can be
linked to the ethical principle of fidelity, or trust. Finally, Level 4 rights are primar-
ily concerned with autonomy, and promoting the developing capacity of the child, or
young person, for greater independence and acknowledging, in the words of the UN
Convention, the ‘evolving capacities of the child’ (UNICEF, 1989: 5).
In practice, the rights of the child or young person might well be in direct conflict
with each other. A child may be entitled to confidentiality (Level 4), but also require
immediate protection from harm (Level 2). The age of the child and an assessment
of the degree of perceived risk are crucial here. Conversely, a young person may be
entitled to privacy in attending a sexual health clinic (Level 4); a parent may claim,
however, to be entitled to be informed of this, given their (assumed) rights as a parent
(Level 1). The model offers an initial way of recognising complementary, competing
and sometimes conflicting rights by all the various parties, who are frequently involved
in accessing counselling services for children and young people.
Clearly, a rights-based approach to ethics has its own weaknesses. Critiques
might point to the implicit emphasis on the value of autonomy, as betraying either
284 The Handbook of Counselling Children & Young People

gender-informed assumptions about desirable developmental norms, or a narrow,

cultural bias towards Western expectations for family life. However, a rights-based
approach does also offer a way of understanding a major anomaly within the field of
counselling provision for children and young people. This is the pronounced influence
of context and institutional setting on professional and ethical approaches to therapy
with children and young people. Practitioner approaches, for example, to confiden-
tiality, can vary enormously between school, medical centre, voluntary agency and
private practice, in a confusing range of apparently inconsistent policies. Given that
the rights of children and young people are heavily determined by institutional con-
text, a rights-based approach can clarify why the same young person can be offered
confidentiality for contraceptive treatment in a general practitioner setting, but be
effectively denied confidentiality in a secondary school, via a policy-based require-
ment for prior parental permission to access counselling (Jenkins, 2013a, 2013b).

Current Issues within Rule-Based and Outcome Approaches to

Ethics

There area number of crucial ethical principles contained in the BACP Ethical Framework,
drawn from a wider tradition of discussion on ethics. These principles include benefi-
cence, i.e. promoting welfare, and non-maleficence, i.e. avoiding harm. Given some of the
factors referred to previously, such as the vulnerability of children and young people, their
developmental immaturity and their dependence on adult care-takers, ethical discussion
about work with this client group often seeks to emphasise the need to promote welfare
and avoid harm, at the expense of limiting autonomy. A consequent shift towards a rule-
following approach seems to be explicit in BACP-endorsed literature on safeguarding,
with the strong recommendation that ‘All therapists should comply with child protection
law’ (Mitchels and Bond, 2010: 38). This tendency also seems evident from recent BACP
policy statements on therapeutic work with children and young people:

BACP believes that the physical safety of ayoung person is paramount and that young
people in counselling will be led to understand that there are certain limits to confiden-
tiality. (BACP, 2010b: 46)
BACP believes that counsellors who work with children and young people should pay
due regard to current legislation, policy and procedures in education. (BACP, 2010b: 46)

The first of these statements seems uncontentious, except that the term ‘paramount’
carries a certain added persuasive authority in any ethical and legal discussion. Taken
literally, this would mean that any risk of physical harm to a person under 18 would
entail a limit to confidentiality, regardless of the expressed contrary wishes of the young
 Ethics 285

person concerned. The second statement appears to present safeguarding law and prac-
tice in education as the template for good practice for all work with children and young
people, rather than considering how best practice needs to take account of differing
opportunities and constraints for promoting adolescent autonomy, as, for example, can
be found in the third, or voluntary, sector.

Ethical Challenges to Maintaining Counselling Confidentiality

No conscientious counsellor would want to place, or leave, a child or young person

at evident risk of harm. However, the reality is that many young clients are already
engaged in risky behaviour, or have a history of being abused, before coming into
therapy. Adopting an ethically-informed stance of always reporting such risk or harm,
against the client's expressed wishes, runs the risk of breaking the therapeutic alliance,
and even of the client later retracting, or minimising, their original disclosures. Daniels
and Jenkins present a sustained argument for providing ‘confidential spaces’ in working
with children and young people and suggest possible factors to consider, in deciding
whether to initiate a report to the authorities (2010: 99). This stance receives support
from a perhaps surprising quarter. The NSPCC presented evidence to the Laming
Review (2009), which argued for a ‘mixed economy’ of services for children, offering
differing levels of confidentiality, in order to provide a range of choices and appropriate
support for children and young people (2008: 32).
Confidential counselling can offer a safe space for young clients to disclose very
private material, often relating to risk of harm or experience of abuse. Research by
Rees et al. (n: 24) emphasises the key relational dimension to such disclosures, i.e. ‘a
consistent relationship with a professional they felt they could trust’ (2010: 52). This
finding is paralleled by Ungar et al. (2009) researching patterns of disclosure of abuse
by young people in Canada (n: 1621). They describe such disclosure as ‘an interac-
tive process; a ‘co-construction. Disclosure of abuse depended heavily on the young
person's perception of the quality of their relationship with a trusted adult.
Brown (2006) found that school counsellors (n: 30) were often challenged by dilem-
mas around confidentiality, with competing demands for information from head or
class teachers, and parents. Jenkins and Palmer (2012) found, in a relatively small-scale
survey (n: 6), that counsellors worked to protect client confidentiality as far as possible,
with the exception of overt child protection incidents, in order to manage high levels of
risk for young clients, without breaking the therapeutic frame. In a relatively rare piece
of research, on the perceived benefits of supervision for school guidance counsellors in
Australia, McMahon and Patton (n: 51) reported on the value of supervision as ongo-
ing support, in ‘reducing the professional isolation’ of counsellors facing ethical and
professional dilemmas (2000: 344).
286 The Handbook of Counselling Children & Young People

Key Issues and Concerns in Ethical Practice with Children and

Young People

It is, perhaps, evident from the foregoing discussion, that there are no easy
answers, in exploring ethical dilemmas in therapy with children and young people.
This discussion will now focus on key areas presenting a major challenge to thera-
PlSts; 1.¢5:

e ethical issues in contracting

e ethics in counselling research with children and young people

Ethical Issues in Contracting

The process of contracting with the child or young person is important, for clarifying
mutual expectations in therapy. This needs to be done in age-appropriate language,
geared to the child or young person’s level of understanding and verbal ability. For
a younger child, starting play therapy will require a very different type of explana-
tion than an older teenager entering into therapeutic work with a mutually agreed
focus. The younger the child, the more likely it is that parents, or adult care-takers,
will be party to the therapeutic contract. In law, children and young people can-
not enter into a contract, with certain very specific exceptions, so any contract for
payment will need to be made with parents, or those with parental or other formal
responsibility for the child. The contract then essentially requires all three parties,
i.e. the child, therapist and those paying for the therapy, to agree the form, focus and
duration of the therapy, with discussion obviously taking account of the child’s level
of understanding. Child psychoanalysts have pointed out that contractual therapy
is usually initiated by the parents, as the child may have limited understanding of
their own distress, or that their behaviours are becoming problematic for others,
or, indeed, of what therapy itself entails. As Anna Freud expressed it, with regard
to therapy for younger children: “The situation lacks everything which seems indis-
pensable in the case of the adult: insight into illness, voluntary decision, and the
wish to be cured’ (1974: 6).
Contracting, from a rights-based approach, is consistent with honouring the child’s
right to participate in decisions, within the limits of their understanding. From an
ethical point of view, the counsellor needs to work within the limits of their own pro-
fessional competence, to refer to more a specialist service if necessary, not prolong
the therapy beyond the point at which it appears to be of value to the client and to
clarify limits to confidentiality regarding any disclosures of abuse, or parental access to
 Ethics 287

detailed information on the therapy itself. Geldard and Geldard set out this aspect of
contracting with some clarity:

We think it is important for parents to understand that it is preferable for the

child—counsellor relationship to be exclusive. Therefore, we tell the parents that
for counselling to be effective their child will need to feel free to talk openly and
confidentially with us. We also say that we realise that it may be uncomfortable for
them not to be kept fully informed of what their child is telling us. However, we
assure them that we will keep them informed with regard to the overall process.
Further, we tell them that if information emerges which they, as parents, have a
right to know, we will talk to the child about the necessity of sharing this with them.
(2002: 45)

With older children, it is important to spell out the limits to confidentiality very clearly
within the contracting process, as young people may not fully appreciate the contextual
constraints on reporting disclosures. Research suggests that retaining some element of
control over disclosures is very important to this older age group, in terms of maintain-
ing their trust in the therapeutic alliance (Rees et al., 2010).

Ethics in Counselling Research with Children and Young People

Counselling research activity with children is driven by the need to promote the
well-being of children. However, research with children is also heavily influenced
by the need to avoid causing harm to them, on account of their age and vulnerabil-
ity, both physical and emotional. The major safeguard employed, to promote the
rights of children within research and to protect them from harm, is via applying
the concept of informed consent. Children, and their parents or care-takers, need to
be able to give valid consent, on the basis of being provided with sufficient infor-
mation, so as to make a reasoned choice as to whether or not to participate in any
research activity.
Following the Inquiries at Alder Hey Hospital in Liverpool and at Bristol Royal
Infirmary, more stringent conditions have been introduced, to protect the rights of
parents and children taking part in both medical and social research. Department of
Health guidance defines informed consent as being ‘at the heart of ethical research’
(2005: 7). This concept is also emphasised by relevant professional codes of ethics
(BACP, 2010b). The age of the child taking part in research is seen as a key factor.
The BPS code on research ethics requires that children and young people under 16
need to have additional consent from their parents, in order to participate (BPS, 2009:
288 The Handbook of Counselling Children & Young People

16). However, it also suggests that this parental consent may be dispensed with, if the
result would be to severely constrain significant research, as long as this approach has
approval from the relevant research ethics committee.
Research ethics committees have been heavily criticised for introducing bureaucratic
procedures into the research process. These procedures can also be notoriously risk
averse, regarding research with children. The effect has been, arguably, to limit couns
elling research with some marginalised groups of children and young people, seen to
be ‘high-risk’ in research terms, such as lesbian, gay, transgendered, bisexual, queer, or
questioning their own sexuality (McDermott, 2010), or young women with eating dis-
orders (Halse and Honey, 2005). From a rights-based perspective, research committees
may thus be in danger of adopting a paternalist or protectionist approach, but at the
cost of denying the potential for autonomy of young research subjects.
Seen from a narrowly legal perspective, research codes may also be in danger
of making a number of errors with regard to children taking part in counselling
research. Firstly, the law requires only the lower standard of consent for research
participation (other than clinical trials), rather than the higher, ethically-driven
standard of informed consent (Masson, 2004: 50). Secondly, children under 16 in
England and Wales can consent on their own to taking part in research, on the
basis of their demonstrating ‘sufficient understanding, following the Gillick deci-
sion. This view is also clearly stated in the Mental Health Act Code of Practice
(DoH, 2008a: Para 36.38).
Best practice in counselling research ethics continues to rest on the process of
obtaining informed consent from children, and, in the case of younger children, also
from their parents or care-takers. The process of obtaining informed consent from
a younger research participant is illustrated below. Here, the researcher was looking
at adoption support services, and initially explained the research to the child’s par-
ents, leaving an information pack for the eight-year-old daughter. In a later phone
call made by the researcher with the permission of the girl’s parents, the girl asked the
following questions about the research itself (DoH, 2005: 12):

e How long do you want to talk to me?

e Will you tell anyone what | say?
e Will you write down what | say?
e Will anyone reading the book know me?
e Will you all come to speak to me?
e What if I’m not sure? Can | change my mind?

In essence, this girl is covering, in her own way, the essential features of confidentiality
and informed consent. Greig et al. (2007: 175-6) define this for children, as consisting
of the following characteristics, depending on their level of understanding:
 Ethics 289

e knowing they have a choice;

e knowing they have the right to withdraw;
e knowing exactly what their role is in the research;
e knowing what will happen to the research data.

Case Study Richmond Moves to Reassure Critics over Catholic

‘Counselling’ Body in Schools
The London Borough of Richmond upon Thames has tried to reassure critics about its decision to
award an £89,000 contract to the Catholic Children’s Society to offer counselling and support to
children in the borough's schools. It comes after Baroness Jenny Tonge - an ex-MP for Richmond
Park — said: ‘It is unfair and irrational for the council to impose Catholic thinking on the entire
population of young people in this borough, the vast majority of whom are not Catholic or may
have no religion at all:
But Richmond Council insisted that staff from the Catholic Children’s Society were committed
‘first and foremost’to their professional standards and ‘not by standards of the Catholic Church’ The
Society, which is accredited by the British Association for Counselling and Psychotherapy, said in a
statement that its counsellors respect other beliefs and would not try to convert or pass judgement
on children.
It said: ‘Issues raised in counselling are therefore explored in a way which respects the autonomy
of the individual receiving counselling. On matters pertaining to sexual health, such as contraception
and teenage pregnancy, we ensure that young people are referred to medical health services where
the appropriate professional advice and guidance can be given. In particular, young people who come
to our counsellors because they are unsure about their sexuality and may be frightened and confused
are treated with sensitivity. On the matter of homophobic bullying in schools, we work with students
to use the appropriate policies and procedures within schools to address this’
The Society was required to sign the Council’s equalities policy before it won the contract in
February (20 May 2011; abridged. Reprinted with the kind permission of the National Secular Society.
& Available at: www.secularism.org.uk/richmond-moves-to-reassure-criti.html accessed 12/11/12).

Summary

e Ethics is concerned with addressing, and attempting to find answers to, key therapeutic
dilemmas
e Professional codes of ethics, such as the BACP Ethical Framework (2010b) offer a framework,
to support counsellors in responding to both everyday and more complex and unusual
challenges to therapeutic practice
290 The Handbook of Counselling Children & Young People

e Approaches to ethics can include rule-following, outcomes-based and the explicitly rights-
based model underpinning the arguments put forward in this chapter
e This chapter follows a very broad distinction, made between children, i.e. 6-11 years, who
are assumed not to be mature enough to make decisions for their own care, and young
people, i.e. 11-18 years, who may have developed sufficient maturity to do so
e Counselling work with children and young people is often considered to be a distinct field in
terms of ethics, because ofthe child or young person's developmental, physical and emotional
vulnerability, requiring correspondingly higher levels of ethical awareness and therapeutic
competence from practitioners

Reflective Questions

1 What are the rights of children and young people in the situation
discussed in the case study?

Children and young people have a number of rights in this situation. They have a right to:

e asay in decisions being made about them, under Article 12 of the UN Convention on the
Rights of the Child (UNICEF, 1989);
e confidential access to information and medical treatment on sexual health and
counselling

o depending on their having ‘sufficient understanding; if aged under 16;

o onthe same basis as an adult if aged 16-17;

e not to be discriminated against in the provision of their rights, under Article 2 of the UN
Convention.

2 How can the rights of children and young people be maintained

and protected in this situation?

e by providing children and young people with full information about their rights, as
required by the UN Convention, under Article 42;
e by independent monitoring and evaluation of the referral patterns, outcomes and satis-
faction levels of children and young people accessing the service;
e by actively involving children and young people in the management of the service, in
ways consistent with their age and understanding.
 Ethics 291

3 How might the rights of children (ie. aged 6-11 years) be

different from those of young people (i.e. aged 11-18 years) when
accessing counselling from this agency?

e differing levels of understanding, leading to more limited entitlement to confidentiality

for children, on the Gillick principle;
e a heightened balance for welfare considerations for children, compared with autonomy
considerations for young people;
* potentially greater scope for counsellor risk-taking with young people, based on
ethically-informed practice.

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Learning Activities

1. Read the case study above:

© should counselling services be awarded to faith-based organisations?

© what ethical issues might this faith-based ‘counselling provision raise for children
and young people accessing this service?
o how might the professional and ethical standards of a faith-based counselling
service be monitored, in order to ensure compliance with equal opportunities
principles?

2. Look at the ethical principles contained in the BACP Ethical Framework (2010b)

o which of these principles are potentially consistent with faith-based provision of a

counselling service for children and young people?
o which principles might potentially conflict with faith-based counselling provision for
children and young people?
o how might any such ethical conflicts be addressed and resolved?

3. Review the material in this chapter on approaches to ethics, i.e.

o rule-following
© outcomes-based
o rights-based

How might each of these ethical approaches be applied to this situation? Where would the
significant differences, if any, be found between these approaches?
¢
8 oe
292 The Handbook of Counselling Children & Young People

Background Material on Activities and Case Study

e In 2009, the Catholic Children’s Society withdrew from the process of approving same-
sex adopters, on the grounds that this was incompatible with the teachings of the
Church. This requirement was brought into law by the Equality Act (Sexual Orientation)
Regulations of 2007.
e The decision by Richmond Council to award a contract for the provision of counselling
services to the Catholic Children’s Society was criticised by gay, secular and humanist
organisations, as being likely to lead to potential bias against, or exclusion from, helping
services, of young people, given the religious beliefs of the provider.
e The Catholic Children’s Society is accredited by the British Association for Counselling and
Psychotherapy, and must comply with its Ethical Framework (2010b). It is also subject to
the complaints and disciplinary procedures of the BACP.
e The Catholic Children’s Society (CCS) has agreed to comply with the Council’s equalities
policy, as a necessary part of the process of being awarded the contract. The CCS has also
stated that it will respect the autonomy of children and young people, make appropri-
ate referrals to medical and sexual health centres, and respond sympathetically to young
people experiencing homophobic bullying in schools and elsewhere.

Using Different Models of Ethics with the Case Study

Rule-following approach: The counselling provision could be monitored by the Council

and by BACP, or by an independent body, to ensure compliance with the existing equal-
ities policy and with key ethical principles, such as autonomy and justice, drawn from
the BACP Ethical Framework.
Outcomes approach: The provision could be monitored and evaluated by the Council,
BACP or by an independent body, to ensure a continuing rate of referrals to gay coun-
selling organisations, and to sexual health clinics. Rates of access (or non-access) by
young people from a range of religious backgrounds, race, ethnicity and sexual orienta-
tion could be audited, to identify the effects of faith-based provision.
Rights-based approach: The ongoing practice of the agency could be monitored
and evaluated, to identify the extent to which attitudes and professional counselling
practice reflected particular models of rights, e.g. potential denial of rights to gay and
lesbian young people; welfare rights of provision and protection from harm; rights to
participation in decision-making; and rights to autonomy consistent with the Gillick
decision.
 Ethics 293

Further Reading

British Association for Counselling and Psychotherapy (2010) Ethical Framework for Good Practice
in Counselling and Psychotherapy. Lutterworth: BACP.
Daniels, D. and Jenkins, P. (2010) Therapy with Children: Children’s Rights, Confidentiality and the
Law. 2nd edn. London: SAGE.
UNICEF (1989) The United Nations Convention on the Rights of the Child 1989. London: UNICEF.

Online Resources

Counselling MindEd: http://counsellingminded.com., especially Module CMD 03: Legal and

Professional Issues.
 19 Diversity
Sue Pattison, Divine Charura and Tom
McAndrew

This chapter includes:

——— EEE
e The importance of transcultural working with children and young people
e Neurological development and damage due to traumatic experiences related to diversity such
as disability, discrimination or asylum and its causes
e Communicating with deaf young people
e Communication with children and young people who have learning disabilities

introduction

Working with children and young people in therapeutic settings is specialist work,
which has many dimensions of influence. Children and young people are a hetero-
geneous group with diversity in language, culture, family histories, social classes, and
experiences of life events. For those who come for counselling or are in contact with
services, their experiences may include abuse, adoption, death of a loved one, and other
multiple levels of loss and trauma. Such diversity of experiences and backgrounds has
led to the development of specialist transcultural and diversity practice. It is not pos-
sible to cover the full range of diversity and related counselling practices.
This chapter can be viewed as a taster, something to whet your appetite for the overt
and covert aspects of diversity. The authors have knowledge and experience in the
 Diversity 295

field of counselling, psychotherapy, education and working in practice with the diverse
range of young clients referred to in the text. Divine and Sue are researchers, therapists
and educationalists, while Tom is a qualified and experienced teacher of the deaf. Each
of us has developed a range of skills and techniques to aid communication and we have
learnt from each other through collaborating on the writing of this chapter. At the
heart of our work we share fundamental values, those of acceptance, empowerment,
the rights of the child, inclusion and a love of humanity.

The Importance of Transcultural Working with

Children and Young People

Transcultural and intercultural therapy was pioneered as a result of dissatisfaction of

therapists trying to apply Eurocentric models of training and practice in their work
with non-European migrants and their families (Kareem and Littlewood, 1992; Lago,
2011). Recognition of cultural, racial, ethnic and the wider impact of socio-political and
economic influences on the therapeutic relationship are important aspects of therapy.
Within the last two decades many parts of the world, including within the UK,
have become increasingly multicultural. This has influenced further development of
transcultural counselling and multicultural practice within therapy (Lago, 2011). As
such, this way of working has permeated not only in working with adults in therapy
but also in working with children and young people whose wider experiences are
reflected in therapy, and they show how they are increasingly influenced and affected
by not only personal but also wider societal and cultural issues. Several factors are
central to transcultural counselling, including the importance of the development of
skills in meeting the needs of children and young people from diverse backgrounds in
the therapeutic relationship and counsellor self-reflection in responding to dynamics
and interventions specific to working with diversity and within transcultural settings.
This will inform practitioners’ thinking when assessing children, exploring issues of
race and cultural discrimination, and will influence decision-making as well as the
therapeutic process when issues of race, culture, disability, and ethnicity are taken into
account. The role of therapy with children and young people is to provide a safe and
ethical way to explore their experiences, unpack their problem story and its cultural
underpinnings, explore their concept of self as a result of the experience and also to
make visible information or perspectives that are neglected through the problem story
filter (Beaudoin, 2004, 2005).
Lago (2006) noted that clinical practice and research indicates just how important
it is for the therapist to both respect and acknowledge diversity and difference in the
therapeutic setting. That is, the capacity of therapists to recognise and value uncondi-
tionally the (diverse) clients and their circumstances. Smith and Widdowson (2003)
296 The Handbook of Counselling Children & Young People

highlighted the importance of child-centred practice. They identified the disadvantages

and experiences faced by black, disabled or working-class children. They postulated a
framework to work from and stated that children who are different will be acutely
aware of their difference and hence will need affirmation for that difference. Children
and young people from minority ethnic groups have specific identity needs relating
to knowledge about their cultural roots/identity and hence it is important to respond
to this as to ignore it may disadvantage them in later life in their understanding
and acceptance or comfort of self (Smith and Widdowson, 2003). Furthermore,
Charura (2012) highlighted the importance of therapists and professionals carefully
considering the hypersensitivity and the skills necessary in working with children
and young people. When working with difference, transcultural counselling is an
example of working with diversity in children that embraces the child’s diversity/
difference. It uses the recognition that within the therapeutic relationship the child
can be helped to integrate their experience and accept their identity and cultural
roots (Charura, 2012).

Counselling Children Impacted by Abuse or Trauma Related to

Their Difference

Unsurprisingly, the children and young people who access therapy or services are
often referred because they have experienced abuse or trauma related to their dif-
ference, which has had a negative impact on their lives. At times they may want
to deal with existential experiences such as disability, discrimination, or other
experiences affecting them. Therefore, it is important for us to be aware of the
growing range of modalities to support children and the research evidence of their
effectiveness. As with any therapeutic approach, such new approaches need to be
viewed with caution and the first intention should be ‘to do no harm’ There is a
large body of literature and research pointing out the dangers of re-traumatising
children by involving them in a retelling of their story, including traumatic experi-
ences (Adam-Westcott and Isenbart, 1995; White and Epston, 1990; Durrant and
White, 1992; White, 2004a). Many of these articles are drawn from family therapy
theory [narrative therapy] which engages people in a process that distances them
from their experience of problems in ways that can allow them to re-examine,
reflect and deconstruct problems’ influence over their lives (Freedman and Combs,
1996; Beaudoin, 2005).
Scott and Stradling (2006) provide information on another approach to working
with children and young people experiencing post-traumatic stress. They suggest four
goals that counsellors can work towards:
 Diversity 297

1. Developing a strong therapeutic alliance/relationship of safety with the child/young

person
2. Obtaining a clear description of the trauma
3. Focusing on working with problematic behaviours
4. Helping the young client to understand the connections between thoughts and feelings

As with all interventions which value anti-discriminatory practice, this way of work-
ing should also at all times consider the differences in children and young people and
influences of culture/experiences on the articulation of emotions and feelings, along
with the child's willingness to engage with the therapeutic process.
Therapeutic interventions for children who have had difficult and traumatic experiences
can be invaluable and it is important that counsellors can offer supportive and therapeutic
interventions that are reparatory and can respond to the needs of a diverse young popula-
tion. Engaging children and young people in therapy or services is specialist work, which
needs to be carried out with expertise, caution and care in order to avoid further damage
or re-traumatisation, leaving both the young person and therapist stuck. Professional
organisations such as BACP, UKCP and BPS provide good practice guidance for working
with children and young people and ethical frameworks that can help counsellors to make
decisions about their practice based on judgements made in relation to potential harm
weighed against the benefits of individual therapies. The issues discussed in this chap-
ter therefore raise important points for therapeutic arenas in the offering of therapeutic
modalities that employ a true valuing of diversity in helping children and young people.

‘goers ira:
Case Study Tarie
Tarie is a young black African girl, aged 14 years. She came to the UK from Rwanda as an unaccom-
panied minor over three years ago following serious political violence aimed against her, which
included rape and torture. Tarie also witnessed most of her family members being killed. She was
referred by a health professional in the UK to an organisation which works with refugees and asylum
seekers following serious concerns of depression and an episode of self-harm. This episode followed
reports of being bullied in school and being called names because she is black.
Initially in therapy, despite being supported to communicate by a translator, Tarie was unwill-
ing to talk about her experiences. However, as the weeks went on Tarie referred to her life prior
to coming to the UK and in particular her childhood experiences. She was forced to be a war
rebel’s sex slave, a child soldier, and described nearly being killed on two occasions. In counsel-
ling, she often described how she felt that she was no longer the person she thought she would

(Continued) <4)
 298 The Handbook of Counselling Children & Young People

~
(Continued)

be. She stated that she had discussions with two adult women from her country she met at the
church she now goes to and told them about her family and her situation. She was informed by
them that that all her life experiences were influenced by voodoo, and transgenerational mis-
fortune. She shared some of her cultural metaphors with the counsellor, including the historical
practices of voodoo and witchcraft in her family, which she had witnessed when she was much
younger. Tarie told her counsellor that a child psychiatrist/psychologist who had worked with
her in the past had suggested that any connotations of voodoo practices were not scientifi-
cally founded and were hallucinations and paranoia. Tarie shared with the counsellor how she
believed that her parents and grandparents whom she had witnessed being killed were now
ancestors who looked over her and helped her in times of crisis and that at times she could hear
her grandmother speaking to her.

Issues raised in this case study include working with trauma, depression, rape, multiple
levels of loss and bereavement, cultural practices, such as voodoo and witchcraft, reli-
gion, beliefs on death and life and also working with a young person who hears voices.
It also raises questions and issues regarding the type of support that can be provided for
such a young person, including the need for a translator.

Neurological Development and Damage Due to Traumatic

Experiences Related to Diversity

Developmental processes are discussed more fully in Chapter 1. However, a brief look
at neurological development here is intended to refresh the reader’s memory and make
the material more accessible when applied to aspects of diversity. The importance of
love and attachments within primary relationships and their impact on children’s mental
and physical well-being is well documented (Joseph, 1999; Gerhardt, 2004). Joseph
(1999) highlighted the relationship between children’s experiences and neurological
development at different age stages.
Van der Kolk (1994, 2005) describes the neurological impact of trauma in child-
hood and how the child’s detachment is expressed in their body, by a ‘shutting down’
of sensation, the body protecting itself from trauma, for example, rape, torture and
natural disasters, as experienced by some children and young people from war-torn
countries who may access our counselling services as refugees. This ‘shutting down’
affects how the child or young person feels, learns and moves in the world as they
 Diversity 299

are developing their vital physical skills. This highlights the neurological impact of
trauma on children’s behaviour and self-concept. This can continue to be evident in
early adulthood manifesting as disruptive behaviour, inability to connect emotionally,
and personality complexities if therapeutic change does not occur. Cook et al. (2005)
identify a wide range of areas in which deficits arise after early relational trauma:
cognition, self-concept, affect regulation, attachment, biology, behavioural control
and dissociation. Goldfinch (2009) concurred with this and further states that when
children experience trauma early in life, when their nervous system is immature, then
the development of their concept of self and of others is disturbed (Drell et al., 1993).
She further argues that young children are more vulnerable to trauma because they
are more dependent on their environment and less able to self-regulate than adults.

Communicating with Deaf Children and Young People

Although there are many types of disability that can affect communication in the couns
elling context (the section following this focuses on young people who have learning
disabilities), hearing impairment can fundamentally affect how a child or young person
communicates and the quality and type of communication possible. Communicating
with young deaf people can be challenging and in order to be effective and make couns
elling accessible, a range of skills, some knowledge and experience is very useful. In this
section we look at some of the considerations you will need to take into account. Over 40
per cent of deaf people have additional special needs, such as autism, Down's syndrome or
other congenital disorders, and they may have physical disabilities or may be deaf-blind.
This section refers specifically to young deaf clients without additional complex needs.

Terminology

The term deaf is often used to refer to people with a hearing loss. However, Deaf with
a capital ‘D’ refers to people who identify themselves as part of the sign language using
Deaf Community. In the UK, the Deaf Community communicates in British Sign
Language (BSL). In reality, there is a spectrum of hearing loss across the frequency
range and it is rarely uniform: hearing loss can be mild, moderate, severe or pro-
found. People with mild to moderate hearing losses may refer to themselves as hearing
impaired or hard of hearing. The latter term is more widely acceptable internation-
ally, although both are used in the UK. For counselling purposes it is important to be
aware of these basic differences in terminology so as to minimise the risk of offence
(Marschark and Hauser, 2008).
300 The Handbook of Counselling Children & Young People

Cultural and Educational Backgrounds

Over 90 per cent of deaf children are born to hearing parents (Knight and Swanwick,
1996) and for most of these hearing parents it comes as a shock to have a deaf child,
especially if there has been no history of deafness in the family. They often go through
a grieving process and may have difficulties accepting their child’s deafness. Hearing
parents of deaf children rarely have sign language skills at the time of diagnosis and
although some parents may take on board learning about deafness, baby signing and
British Sign Language (BSL), others may choose not to learn BSL — they may not have
the necessary motivation to learn this language or indeed be advised not to learn it by
some, otherwise well-meaning professionals.
Many deaf children of hearing parents (DCHP) take an oral pathway in education
and are fully integrated into mainstream schools or go to mainstream schools with a
hearing impaired (HI) unit attached. Consequently these children have not grown up
as members of the Deaf Community and may not have developed the sign language
skills to communicate that enable communication with this community. They do not
necessarily share the same cultural values and could feel they belong more to the wider
hearing community, an issue around diversity that counsellors may need to be aware of.
Many of the 10 per cent of deaf children of deaf parents (DCDP) are members of
the Deaf Community from birth since they more are likely to grow up with BSL as a
preferred/first language and have contact with Deaf Clubs and organisations associated
with the Deaf Community from an early age, which helps to nurture a distinctive Deaf
culture. Deaf parents are more likely to opt for a sign-based educational pathway (e.g.
Total Communication or Sign Bilingual Education) for their deaf children. However,
it needs to be emphasised that some DCDP take oral pathways in education and some
DCHP take sign-based educational pathways, which means that forms of communica-
tion cannot be assumed by the counsellor. The pathway taken depends on the level
of hearing loss, aids used (e.g. hearing aids or cochlear implants) and the availability/
type of specialised deaf education institutions near to where they live and, of course,
parental choice.
Deaf children, especially teenagers and young adults, could be very confused as to
whether they belong to the Deaf Community or not. A deaf child whose preferred lan-
guage is spoken English and has more of an affinity with the wider hearing society may
join the Deaf Community through later association with its members. It is also impor-
tant to realise there are different sign languages for each country and there are regional
variations within countries too. Deaf people from ethnic minorities in the UK will also
have been exposed to their parents’ native language (whether through speech sounds
or writing) as well as another sign language. Deaf and young people who have sought
refuge in the UK with or without their families may be more vulnerable regarding lack
 Diversity 301

of communication than others due to their exposure to trauma, loss and unavailability
of sign language translators from their linguistic or cultural background. In addition to
these difficulties, some young people may have been deafened through the violence of
armed conflicts without any opportunity for treatment or education in forms of com-
munication. Their experience can be extremely traumatic and enduring.

Methods of Communication

There are various ways of communicating with young deaf people. BSL and other sign
languages have already been mentioned as well as speech for mild to moderately deaf
people (or deaf people with cochlear implants). However, there are also other sign
systems that can aid communication with young deaf people. Although the exam-
ples presented here cannot be detailed, there is much information available through
a range of internet websites. Examples of other sign systems include: Sign Supported
English (SSE), Manually Coded English (MCE), Seeing Exact English (SEE), Signed
English (SE), Cued Speech, Paget-Gorman, Makaton and Finger-spelling (Knight and
Swanwick, 1996). These systems are mainly used in deaf education to help support and
encourage speech, written grammar, spelling (Finger-spelling) or to communicate on a
basic level with deaf people with complex needs (Makaton). It must be emphasised that
they are not languages; they are methods of communication used by professionals and
deaf people in specific contexts.
This section does not describe the full variety of communication systems in detail.
However, if a young client does express a wish for one of the above systems to be used
then the counsellor may consider learning more about this particular method or con-
tacting a competent user to act as a form of interpreter. Another aid to communication
includes lip-speaking. A trained lip-speaker can use facial expression and clearer lip
patterns to make the speaker more easily understood. This is an option that also needs
taking into consideration by the counsellor.

Long-Term Preparation for Communicating with Deaf People

Going on a Deaf Awareness course is a fundamental starting point for counsellors who
want to work with young deaf clients. The next step would be to start learning BSL,
ideally progressing to a highly competent level but at least to a basic level so that intro-
ductions and basic conversations can be held. This would reassure the young deaf client
that their counsellor is aware of their language and culture and have the effect of putting
them at ease and promoting the development of a stronger therapeutic relationship.
302 The Handbook of Counselling Children & Young People

Eventually being a fluent signer of BSL will enable a counsellor to directly com-
municate effectively to young members of the Deaf Community without recourse to
booking an interpreter. Two-way rather than three-way communication will lead to
more effective counselling and safeguard against confidentiality issues (interpreters, by
the very nature of their job, will be privy to very personal information about the deaf
client). However, counsellors cannot assume that young deaf clients value confidential-
ity in the same way that hearing clients do; by the very nature of the world in which
a deaf young person operates, familiarity may foster greater trust and confidence. If a
BSL-English interpreter is required, BSL users usually have a preferred interpreter who
may be a family member or someone they use on a regular basis in contexts other than
counselling. The young deaf person may feel more comfortable with an interpreter
they are familiar with. Many parents and guardians of deaf young people will book an
interpreter themselves but it is wise to check just in case the family expects the counsel-
lor to organise this service. Also, it is prudent to have the contact details of one or two
BSL/English interpreter agencies in case the client’s usual interpreter is not available.
The issue of funding for interpretation services should be addressed by all counsellors
prior to beginning a therapeutic intervention. The initial assessment stage of counsel-
ling may need to be longer to make sure that the needs of the young client are met in
the most effective and appropriate way.
There may be other difficulties around the provision of communication support for
young deaf clients, for example, family members who take on the role of interpreters
for their children may not be ideal during counselling sessions because their signing
skills may not necessarily be of a high enough level. In addition, the child’s trust or
confidence in their family members, especially when discussing sensitive personal feel-
ings, cannot be guaranteed. Most competent BSL/English interpreters will be members
of the Association of Sign Language Interpreters (ASLI) and work to a Code of Practice
that includes confidentiality in relation to the content of their interpretation.

Deaf Awareness

The following guidance cannot replace a course on Deaf Awareness but it can help
counsellors with the basics. Regardless of the client's level of hearing loss, it is good
practice to always face the client whilst talking/communicating, to speak clearly and
evenly rather than exaggerating facial expressions. The background environment is
also important, with the counsellor being more visible when sitting in front of a plain
background, rather than, for example, highly patterned wallpaper or pictures. It is more
difficult for a young deaf client to lip-read the counsellor or interpret signs, if using
BSL, with an irregular background.
 Diversity 303

It is useful for counsellors to have an awareness of the range of technology to help

deaf young people maximise the use of their residual hearing (remember, most deaf
people are not profoundly deaf). For many, a particular model of behind-the-ear (BTE)
digital hearing aid or one of the other types of hearing aid will be worn. More and more
deaf young people have cochlear implants and the recent trend is for young people to
have cochlear implants for both ears. However, these are simply aids to using residual
hearing — not cures for deafness.
When using a BSL/English interpreter, it is good practice for the counsellor to always
address the client, not the interpreter. It is useful to be aware that there will be a short
time delay between the words you have spoken and the interpreter’s signed translation.
BSL interpreters work to a strict Code of Practice and if there is only one translator, the
counsellor should make sure they give the interpreter short breaks every 15 minutes
since it is a very intense and tiring activity. If you want to get your client’s attention,
tap them on the shoulder or give a hand signal that is appropriate and clearly visible
(mainly for severe to profoundly deaf clients; for mild to moderately deaf clients this
may not be required). This may go against some counsellors’ practice of not touching
clients. However, in order to provide an appropriate service to young deaf clients, flex-
ibility rather than rigidity is essential.

Counselling Young People with Learning Disabilities:

A Proactive Process

In this section we put forward a proactive process through which counsellors can
‘step out, reach out and move out’ to include young people with learning disabilities
in mainstream counselling. The concept of being proactive was addressed by Viktor
Frankl in his book Mans Search for Meaning (1946) and has at its heart a process of
taking responsibility, not looking to others or outside circumstances, but having the
courage, perseverance, awareness ofthe existence of choices, regardless of the situation
or context. Martin (2001) refers to Frankl’s work in his assertion that ‘the active choice
is to play the game; the proactive choice is to change the rules of the game, especially
when therules ofengagementare unfair. Therules of ‘the game are inherently unfair for
young people who have learning disabilities, by definition present during childhood,
impacting on developmental processes and manifesting in a variety of ways including
the presence ofa significantly reduced ability to understand new or complex informa-
tion, to learn new skills (impaired intelligence, usually an IQ below 70; WHO, 1999),
with reduced ability to cope independently leading to impaired social functioning
(APA, 1994; WHO, 2003). The major argument for specifically including young
people with learning disabilities in counselling rests on four major premises. Firstly,
304 The Handbook of Counselling Children & Young People

the low level of perceived well-being among young people with learning disabilities
in the UK (UNICEF, 2007) and their high level of emotional distress and psycholog-
ical problems (NSPCC, 2007; WHO, 2001); secondly, and more specifically, the high
level of mental health problems in young people with learning disabilities referred to
as ‘dual diagnosis’ (Raghavan and Patel, 2008; NSPCC, 2007; Allington-Smith, 2006;
Royal College Psychiatrists, 2004). Thirdly, the international human rights move-
ment and literature on human rights (Morrall and Hazleton, 2004; Shakespeare,
2006) and national social inclusion policies (HM Government, 2006; Social
Exclusion Unit, 2004; Ofsted, 2004). Finally, national policies aimed at addressing
the needs of children and young people in contemporary society (DfES, 2003, 2004a)
form the political canvas against which practices may be funded and developed.
How can school counsellors become more inclusive? Human rights policies that
provide the impetus for inclusive counselling are the Disability Rights Commission
Act (1999); Human Rights Act (1998); United Nations Declaration of the Rights
of Disabled People (1975); United Nations Convention on the Rights of the Child
(1989); United Nations Standard Rules in the Equalisation of Opportunities for
Persons with Disabilities (1993); and the National Advisory Committee on Creative
and Cultural Education (1999).
Research carried out by Pattison (2010) indicates that counsellors who are proactive
in raising awareness of the service to young people, their parents or carers, and within
organisations working with young people (reaching out) and who provide inclusive
initial assessments, found that the level of inclusivity in their practices and processes
increased and they saw more young people with learning disabilities in their counsel-
ling rooms. Similarly, a proactive use of advocacy through the young person's teacher,
support worker, parent or peers improved inclusivity. Moreover, an integrated part-
nership approach, including building relationships with parents/carers, school staff,
statutory health and social care professionals, and/or voluntary agencies and charitable
trusts, raised inclusiveness in counselling. This can be aligned with national polices
supporting the needs of young people (DfES, 2003, 2004a); DoH/HO, DfEE, 1999) and
provides the ‘bottom-up’ approach that can make ‘wrap around care’ policies work in
practice. In order to support these processes counsellors may require specialist training
in learning disability issues leading to the paradoxical position of specialist training
leading to more inclusive practices in the mainstream context. In Pattison’s (2010)
study, linked to counsellors’ expressed need for specialist training was the need for
experienced supervision. In the school context counsellors’ requirement for supervi-
sors experienced in working with children and young people, along with knowledge
and experience of the school context, is well documented (WAG, 2008; BACP, 2006).
However, no mention is made of the value of knowledge and awareness of learning
disability issues. This highlights the poor visibility of this client group in mainstream
policy documents.
 Diversity 305

The most inclusive counsellors are clear about what works for them and they pro-
actively include young people with learning disabilities in both their practices and
processes. By far the most effective factor is building relationships, with the client,
with members of staff who have enabling roles in schools, health and social care
services, and parents/carers. In terms of specific client work, the engagement and
process of counselling is enabled through proactive relationship building and
communication. Pattison (2010) found that by trying out various imaginative and
creative approaches and the use of simplified language, most importantly at the ini-
tial assessment stage, counsellors discovered ways of communicating that worked.
The barriers to inclusion were largely located in systems, for example, resources,
time, money, and training. In order to overcome these barriers, a proactive approach
to the operationalisation of equal opportunities policies is recommended, and this
brings us back to the quote at the beginning of this section by Martin (2001) with
reference to Frankl’s (1946) work. The overt rules of the game appear inclusive,
supported by policies and legislation. However, the hidden organisational, social
and political discourses, or covert ‘rules of the game, may differ and relate more
to resource management and educational, health and social care agendas that are
adopted by organisations in response to central policies, for example meritocratic
goals and league table achievements in schools and a hierarchy of resource distribu-
tion in the NHS and social care services (DfES, 2004b, 2008). These dual discourses
and agendas may extend into the counselling service, impacting on practices and
processes in ways that can exclude some young people from counselling when they
may benefit from the service, for example, referral for behavioural programmes when
the young person’s behaviour is an external expression of their emotional distress.
Martin (2001) proposes that Viktor Frankl’s proactive stance builds upon foreknowl-
edge (intelligence) and creativity to anticipate and see situations as opportunities and
to influence systems constructively for the good of the client.

Summary

As identified in the introduction to this chapter, working with children in therapeutic settings is
specialist work. We identified that children and young people are not a homogeneous group and
display diversity in language, culture, family histories, social class, and life experiences. The reasons
for therapy are also diverse, and young people's experiences may include abuse, adoption, death
of a loved one, and other multiple levels of loss and trauma. It has not been possible to cover the
diversity and related counselling practices. Therefore, this chapter has focused on:
full range of
(Continued)
 306 The Handbook of Counselling Children & Young People

(Continued)

e transcultural working with children and young people

e neurological development and damage due to traumatic experiences related to diversity such
as disability, discrimination or asylum and its causes
e¢ communicating with deaf young people
e communicating with young people who have learning disabilities

Reflective Questions

1 What challenging issues can you identify in the case study —

Tarie?

The challenging issues are those that any counsellor could face with a young client:
working with risk in terms of psychological holding and self-harm, listening to sto-
ries of severe trauma and violence and being ‘with’ Tarie, yet keeping self safe. There
are also issues of spirituality that may be in line with or against your own belief
systems.

2 What therapeutic approach would you take in supporting Tarie?

A transcultural approach would involve listening to and accepting Tarie’s accounts of

her experience within a framework of cultural and spiritual material that may be very
different to your own.

3 How could you prepare for future work with deaf children and
young people?

By taking a Deaf Awareness course in the first instance, you will become more
aware and knowledgeable in respect of issues that may impact on your young deaf
clients and learn more about methods of communication. Further preparation
would include courses in British Sign Language, or the sign language of your own
country.
 Diversity 307

srs Ne ese ToS AE el Thee Pee Monel Tort Mh AP Ia tS YN at ea

nN
Learning Activities

1. Make contact with your local Deaf Club - the College of Further Education in your area
will be able to provide contact details. You may be able to visit and get to know some
useful contacts, building up a network to draw upon when you need a BSL translator or
advice and guidance on deaf issues.
2. Look at the anti-discrimination policies in your counselling setting and assess accessibil-
ity for children and young people of difference.
3. Get to know the local community where you are based for your counselling work, and
get a feel for issues around diversity that impact generally in that community.
s ¢

Further Reading

Glickman, N.S. (2013) Culturally Affirmative Psychotherapy with Deaf Persons. New York: Routledge.
Lago, C. (ed.) (2011) The Handbook of Transcultural Counselling and Psychotherapy. Maidenhead:
Open University Press/McGraw-Hill.
Zand, D.H. and Pierce, K.J. (eds) (2011) Resilience in Deaf Children: Adaptation through Emerging
Adulthood. New York: Springer.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com. MN8 Cultural Competence and Equalities
Issues for CYP and Families, MN 8.01, MN 8.02, CM.
 Bereavement
Maggie Robson

This chapter includes:

ee
e Loss and bereavement
e Whether therapeutic interventions can help children and young people who have experi-
enced significant loss
e The differences when working with children and young people
e The theoretical underpinning of the experience of grief and its relationship to attachment and
developmental stage

Terminology and the Loss Experience

Bereavement and loss are terms which are often used interchangeably but which have
slightly different meanings. Bereavement is commonly used to mean mourning after
the loss by death of a significant person in our life. Loss may be described as any loss
experience that causes an individual to re-evaluate their worldview, as well as their past,
present and future, as a result of that experience. Loss can thus encompass bereavement
and can include the results of other experiences such as divorce, abuse, death of a pet
and moving house. This re-evaluation means that we can no longer take for granted
assumptions about our world; our assumptive world changes (Lewin, 1935; Parkes,
1993). For example, if a young girl’s mother dies, she can no longer assume that her
 Bereavement 309

Mum will greet her at the door on her return from school. She can no longer assume
she can share the ups and downs of her day with her. A small boy can no longer assume
that his older brother will be there to protect him in the playground or to play football.
However, we need to have assumptions in our internal world in order to function as a
psychologically healthy people. The process of bereavement, therefore, is about adapt-
ing to these losses in our internal world and restoring a degree of denial that life is
transient and fragile.
Loss is strongly connected to change as most change involves some loss and loss
always involves change. Parkes (1993) argues that bereavement may be viewed as a pro-
cess of adaptation to change (a psychosocial transition) whilst also acknowledging the
role of attachment in shaping our responses to loss. The significance of the loss experi-
ence may not necessarily be confined to physical loss but can be symbolic in nature,
depending on the meaning the individual attributes to the experience, for example, lost
childhood due to abuse.
Grief is the result of experiencing both bereavement and loss and is the process
we go through when mourning. In bereavement, we may be consumed by images
and thoughts of the dead person, feel overwhelmed by sadness and also experience
more unexpected emotions such as guilt that we have survived or that we did not
prevent the death, anger at the dead person for dying and leaving us, relief that the
dead person is no longer in pain or even relief that the dead person is no longer
able to harm us. In other losses we may experience a similar complex and pos-
sibly ambivalent mix of thoughts and feelings which may have an effect upon our
behaviour.
The emotions we experience when we are bereft can be overwhelming - we can
feel that we will never be able to function ‘normally’ again or be the same as we were
before the experience. Although most theories of loss and bereavement (Bowlby, 1980;
Worden, 1991; Stroebe and Schut, 1999) tend to talk about adjusting to the loss and
disengaging from the deceased in order to reinvest our emotional energy in others,
Silverman and Klass argue that the process of mourning is about maintaining the rela-
tionship with the deceased, albeit in a different form:

rather than emphasising letting go, the emphasis should be on negotiating and
renegotiating the meaning of the loss over time. While the death is permanent and
unchanging, the process is not. (1996: 18)

If our loss is significant, it may be that part of us always remains grieving (Hunt, 2004).
This does not mean that we cannot still lead satisfying and fulfilling lives but that our
grieving self will always be with us, sometimes very much in the background of our
lives, but sometimes in the forefront, and can feel as raw as when first experienced.
This rawness, however, may be present less and less as time passes. The effects of loss
310 The Handbook of Counselling Children & Young People

can be imagined as being like ripples in a pond after a stone has been thrown in with
the biggest waves nearest the stone and getting smaller and gentler as they get further
away. However, big waves can come and take us by surprise! The effects of loss can also
be physical - we can feel as if our heart is breaking and, in fact, the experience of grief
can be linked to depression, somatic symptoms and interpersonal problems (Goodman
and Brown, 2008).

Is Therapeutic Intervention Helpful when Children and Young

People Experience Loss?

All human beings are driven to try and make sense of their experiences even though, in
the case of significant loss, there may seem to be no sense to it, and the grieving process
is a way of making this sense. Counselling can help us to do this but may not always be
the most appropriate response for children and young people.
Bereavement and loss can be viewed as a ‘natural’ part of our experiencing. There is,
therefore, a debate about whether counselling is appropriate for people who have expe-
rienced loss as loss is a normal and natural part of our life, not something pathological
or unusual (Bonanno and Lilienfeld, 2008). Parkes (1998) suggests that there is:

no evidence that all bereaved people will benefit from counselling and research has
shown no benefits to arise from the routine referral to counselling for no other reason
than that they have suffered a bereavement.

However, just because these may be universal experiences, it doesn’t make them less
painful or individual. Grief is a process that is both unique to the loss we experience
and to us as people.
Counselling, both for children and young people and for adults, can be helpful if
normal social support is either not available or if it is limited in some way, and/or if
the grief is complicated or the effects last for a long time. Adams (2012) argues that:

Grief is not an illness or a condition, it is normal, as are extreme responses to it. It is

when these responses continue into the long term that there may be cause for concern.
A young person will not get over their grief, but with timely and appropriate support,
they will hopefully learn to live with it. If it is preventing them from engaging with nor-
mal life, do not hesitate to seek help. Most young people will not need professional
help but some will need a bit of extra support. Others will require a more in-depth
approach with bereavement counselling, or therapy.
 Bereavement 311

Children and young people may have a very supportive social network but often
the most intimate supporters (family and friends) are also devastated by the same
loss and so are unavailable. Sometimes, the young people are afraid to utilise the
family support for fear of upsetting the people around them and sometimes the
people who could be of most support feel as though they haven't the knowledge
or expertise to help. Adults may find it easier to deny the idea that the child might
be grieving. Perhaps, because we all share a knowledge of the impact and pain of
loss on ourselves, we can find it difficult to witness this in children and young
people and are tempted to downplay the effect that it may be having on them.
‘She's too young to understand what’s happening’ is not an uncommon response to
a bereaved child. It can sometimes feel overwhelming for us to witness the pain of
a young person and can feel more comfortable if we minimise, in our minds, the
pain we are seeing.
Additionally, it is important to acknowledge, children and young people do
understand death differently and grieve differently to adults and this is sometimes mis-
interpreted as them being unaffected by the loss. Although they may experience the
same range of feelings as an adult and process the loss in a similar way, they may lack
the conceptual skills to talk about it and their distress may become apparent through
their behaviour (Pennells and Smith, 1995: 9). In my experience, therapeutic help can
be of benefit when this occurs.
In situations where carers lack the confidence to work with the child or young
person, perhaps the most helpful thing a professional therapist can do is to support
the family/friends to support the young person. This can be done through information
giving and talking through what may be helpful.
Counselling may also be helpful if the grief is complicated by unsureness about
how we felt about the deceased. Although we are often taught not to speak ill of the
dead, some of the significant losses we experience are of people with whom we had an
ambivalent relationship and perhaps even hated. This can lead to a complicated grief
response. The type of loss can also trigger more difficult grief responses; for example
sudden, unexpected loss, loss by suicide, murder, and loss where the body is unre-
coverable or not found. Children and young people may also need to mourn a loss at
different stages of their lives. For example, a young girl whose mother died when she
was six may mourn the loss again when she goes to secondary school, gets married,
has her first baby and at other significant points in her life. Also, we may not recognise
the full impact of the loss at the time but may come to recognise it gradually or at a
later date. For example, a child who has been adopted and has no details of their birth
family’s medical history may grieve anew when a doctor asks if some condition ‘runs
in the family.
312 The Handbook of Counselling Children & Young People

History and Background

In its present form, counselling has only been available in the UK since the 1950s
although helping with psychological distress has historically been a part of the func-
tion of all societies (McLeod, 2009). Bereavement counselling similarly has a short
history. Perhaps the best known charity offering bereavement counselling in the UK
is CRUSE, founded in 1959. Its initial remit was to help bereaved adults although it
now offers a website for bereaved young people. Initially, bereavement support services
rarely extended their work to children and young people but recently these services
have been developed (Rolls and Payne, 2003). Some local therapeutic services are avail-
able and schools who offer access to counselling often find bereavement and loss to be
a common issue brought to therapy. Cooper (2013) reports that bereavement issues
make up about 10 per cent of the concerns that young people attending counselling in
schools present.
There is little research into the efficacy of therapeutic interventions with children
and young people who have been bereaved (Wilkinson et al., 2007). The lack of
research using randomised control trials (RCT) is perhaps understandable given the
ethical issues raised in denying some of the population support during bereavement,
but qualitative research is sparse too. Wilkinson et al. (2007) attempted a RCT trial
but had to abandon it due to lack of participation, but they did conduct a study of
parents’ perceptions of a family bereavement support service in seven UK hospices.
They concluded that ‘support interventions can have a positive impact on post-
bereavement adjustment. It is an interesting study but has quite a limited scope and
more research needs to be developed to examine more fully the efficacy of bereave-
ment work with children and young people and also needs to include the views of
the children.

Theory that Tries to Explain Responses to Loss in Children and

Young People

Why do we grieve? We grieve because we have lost something or someone with

whom we had formed an attachment. Parkes suggests ‘that it is the nature and
quality of the attachment that determines the intensity of the grief, rather than the
magnitude of the psychosocial transition that results’ (1993: 246). In other words,
it is the importance we attach to the loss rather than the disruption in our lives
that affects the depth of our grief. This seems to be true whether the attachment
 Bereavement 313

experienced is positive or negative or, in Bowlby’s (1969, 1973, 1980) terms, secure
or insecure. This concept is explained in detail in Chapter 1, ‘Child Development
and Attachment’
The idea that early relationships are important in healthy development permeates
all development theory, and it is interesting to note that attachment theory implies a
causal relationship between loss and our responses and is seen, as Fraley and Shaver
report, to determine our grief responses:

whether an individual exhibits a healthy or problematic pattern of grief following sepa-

ration depends on the way his or her attachment system has become organised over
the course of development. (1999: 740)

Bowlby (1969, 1973, 1980) conceptualises grief as separation anxiety (caused by sepa-
ration from an important attachment figure), so the way we manage grief is dependent
upon our attachment style and whether the ‘internal working models’ we hold in mind
are positive or negative. Broadly, secure individuals are believed to be able to recognise
their losses and be able to deal with them and able to seek support. Anxious-ambivalent
individuals are thought to focus on their distressing thoughts and feelings more in
order to maintain contact with the person or thing they have lost. They may have diffi-
culty ‘moving on. Avoidant individuals are thought to be more likely to minimise their
grief and to ‘move on quickly (Cassidy and Shaver, 1999).
There do seem to be some commonalities within models of the grieving process, as
seen below, but the intensity, duration and experience is a very individual one. Most
models of the process suggest that it is either phased (moving through various phases
of grief, e.g. Bowlby, 1980; Parkes, 1986), tasked (having to complete a variety of tasks
to successfully negotiate the process, e.g. Worden, 1991) or an oscillation between
grieving and coping, as in the Dual Process Model (Stroebe and Schut, 1999).
Bowlby’s phase model is derived from his attachment theory and has similarities with
the phase model proposed by Parkes (1986), where the following phases are identi-
fied: numbness (denial and shock), pining (yearning and protest), disorganisation and
despair, reorganisation (recovery).
Stroebe and Schut’s (1999) DPM describes our grieving process as an oscillation
between focusing on the emotions surrounding our loss and avoiding the loss. We
engage in restorative behaviour as well as experiencing the meaning of our loss. Stokes
et al. (1999) suggest this model is useful in helping us understand the behaviour of
children and young people in managing their grief. They suggest, for example, that if
the child or young person senses the adult is distressed when talking about the dead
person, they may attempt to distract the adult or avoid talking about the dead person
314 The Handbook of Counselling Children & Young People

themselves. This can be a helpful strategy but can also be misconstrued by the sur-
rounding family and friends as an indication that the child or young person is not
affected by the loss.

How Children and Young People May Grieve

Although all of these models may help our understanding of the process of bereavement
and loss children may experience, we need to remember that grief is unique. Children
and young people understand death differently at different developmental stages and are
likely to deal with it in a different way to adults (Slaughter, 2005; Himebauch et al., 2008).
Four concepts are commonly used in the literature (e.g. Willis, 2002; Orbach et al.,
1986) to judge whether children and young people understand death or not. These are:

. Do children understand that death is irreversible?

. Do they understand it is final?
Do they understand it is inevitable, that all living things die?
wnaDo they understand causality, that there is a physical cause to death — the body stops
working?

There are huge differences of opinion about the age at which a child can understand
these concepts, with some authors believing that children as young as six months can
understand and others believing understanding only emerges in adolescence (Willis,
2002: 222). Broadly, however, understandings that children and young people have
relate to the developmental stages they have reached which are, in turn, related to
the development of cognitive understanding. As suggested in Chapter 1, Piaget (1965
[1932]) argued that children’s thinking is structurally different from that of adults
and suggested a theory of cognitive development based on the way that children and
young people at different ages function. These ideas can be used to understand chil-
dren’s developing concept of death and dying (Himebauch et al., 2008).

The Development of the Concept of Death in Children and

Young People Related to Developmental Stage
Sensory Motor Stage: 0-2 years approximately

Normally, there appears to be little cognitive understanding of death or loss but the
child does respond to separation and is often very in tune with parents’ emotions.
However, Raphael (1984) suggests that we may be unconsciously aware of our losses:
 Bereavement 315

David, a young man of 22 who saw a dead woman being taken from the site of
an accident on a stretcher. Her arm was hanging over the edge and her breast was
partially exposed. This awakened a vivid and previously repressed, memory of his
attempts to suckle the breast of his dead mother when he was 10 months old. (p. 79)

Pre-operational Stage of Development: 2—7 years approximately

Up to around five years, a child is usually able to use words about death relatively
appropriately but really it seems to be ‘pretend’ and there is little concept of the irre-
versibility or finality of death. It is common to confuse death with sleeping and death
may be seen as a punishment. They may feel they have caused the death although
guilt is acommon feeling associated with grief right through life, including adulthood.
We need to be very careful with the language we use to explain death as the misun-
derstanding reported by Raphael (1984) demonstrates:

Jason (2%) ... He and his father used to go to a nearby airport to see planes
together. When his father, to whom he was intensely attached, died, he was told
he had ‘gone to Heaven to be with Jesus’.’. he ran away on many occasions and
was found ... [near the airport] where he had gone to‘get in a plane to go to the
sky to Daddy’ (pp. 86-7)

Between the ages of around five to eight years, children gradually see death as pos-
sible but not for them, and usually associate death with old age. They begin to accept
that death is an end and begin to realise death is not reversible. They often have a real
curiosity in the idea of death.

Concrete Operational Stage: 7-11 years approximately

Children are much more able to see death in abstract terms and can understand as much
as people will tell them. They begin to realise death may include them and to understand
the irreversibility of death. They are able to differentiate between living and non-living.

Formal Operational Stage: 11-16 years approximately

The young person begins to have a more adult understanding. Because they are able
to think more abstractly, they understand implications of death more fully. It is pos-
sible that some may think suicide is a means of getting back at someone, but they
may also see it as reversible (as some survive) and re-occurrable (as some try more
than once). Desperate young people can engage in risk-taking behaviour which can
result in death.
 316 The Handbook of Counselling Children & Young People

The descriptions of Harry Potter’s experience of Dumbledore’s death provide an illus-

tration of the range of emotions an adolescent might experience — sadness, mirth,
regret, curiosity, suppression of emotion, accumulation of grief and loss, isolation
(Rowling, 2005: 599-600).

ie =
Case Study Sharon
Sharon was nine years old and was referred because her older brother was killed in a car accident
which Sharon witnessed. She, understandably, was having difficulty processing this experience.
Her mother, because of her own distress, felt unable to offer Sharon appropriate responses to her
questions about the death of her brother, and because Sharon’s ‘supporters’ were also bereft they
were unable to help her to find a voice for her feelings of loss.
Sharon and | met for ten sessions of play therapy where the purpose was to use the child’s natural
medium of communication, ‘play, to make some sense of her experience. Rather than interpret the
meaning ofthe play, | look for themes and the themes in her play were predominantly about making
order out of chaos and about nurturing. She rarely talked directly about her experiences or acknowl-
edged her feelings.
The major theme of Sharon’s play was nurture. She played most of the time with the doll’s house
which ‘Mammy’ or ‘Daddy’ kept clean and where they looked after the children. In session two, a
new theme occurred through her stories, that of sudden happenings, then things returning to
normal, but nothing ever being the same again.
Sharon's play became much more expressive in the seventh session and she spoke for the first
time of the things that had happened to her. She again played with the doll’s house and the theme of
creating order out of chaos was apparent.
Session eight seemed to mark a change in Sharon’s behaviour. She was much more assertive and
more playful. The themes included being in control and, although terrible things happened in her
stories, they had a happy ending and seemed less chaotic. This continued in session nine.
In session ten, themes of order and normality were very apparent and the session seemed very
peaceful. Her play was still very ordered but seemed less stressed. The children in the doll’s house
did not seem to need quite so much looking after and could be very independent.
The final session was a very tranquil session and old themes and play were re-visited. The chaos
seemed to have receded and some sort of order established in her life. Perhaps the therapeutic play
space had allowed her to make some sense of her experience.
,
Summary
SALLE ESOEE EELS EIT EEE LSE SOLIS ESIE GOELLER LIB LEEE IEEE ERE ELISE LE CELE

How a counsellor works therapeutically with children and young people who have been bereaved
will depend upon their theoretical orientation (see Chapters 2-8 in this handbook). However, in
this chapter | have suggested:
 Bereavement 317

The meaning associated with the loss is what is central in understanding the loss and to work-
ing with grieving children and young people
Reactions to loss are individual and range from feelings of sadness to serious physical, emo-
tional, behavioural and cognitive reactions
Responses are dependent both on the meaning of the loss and the development stage ofthe
child or young person

In addition:

To understand how children and young people perceive loss and grieve, it is important for
us to appreciate how working with this issue with this population may affect us. It is often
very difficult to witness pain in others, especially if we see the others as vulnerable children.
This may make us reluctant to ‘hear’ the children, so we need to make sure we are well sup-
ported
How we work therapeutically with our young clients will depend upon our training, orien-
tation, work setting and experience, but we all need to be aware of the possible effects on
us. Working with loss can make us aware of our own mortality and the mortality of those we
care about, and we can become supersensitive to risk, which can be paralysing
We need good supervision and good self-care in order to keep ourselves open to our clients
and safe

Reflective Questions

Some of these activities, as with all personal development work, may be upsetting, so
make sure you are well supported if you choose to do them.
tle Think about a loss you have experienced; write down an account of your process. Does it
fit in with any of the models of grief described in Table 20.1? Where is it the same, where
different? Why might that be?
. How well do the descriptions of how death is conceptualised at different developmental
stages in the Box above fit with your experience of children and young people? Where is
it the same, where different? Why might that be?
. Why is it important to keep parents and carers ‘on board’?
. What strategies would you use to do this whilst still maintaining confidentiality?
. When do you think it would not be appropriate to offer a therapeutic intervention to a
bereaved child or young person?
. You are working with children and young people who are bereft. What support do you
have? How will you look after yourself so you can be open to listen to your clients?
318 The Handbook of Counselling Children & Young People

eS — Se |}!
————————————————————————————————————
é
| Learning Activities
i
i
Again, some of these activities, as with all personal development work, may be upsetting
i
so make sure you are well supported if you choose to do them.
i
Theory suggests that our response to loss is associated with our attachment style. When
q
working therapeutically with loss, our own attachment style as a therapist can impact upon
i
| our work, so the first two activities are designed to help us explore our own styles.
i
1. Answer the following questions by yourself, then discuss with a partner:
i
i i. Who do you like to spend most time with? Why?
ii. Who do you miss most during separations? Why?
iii. Who do you feel you can always count on? Why?
i
iv. Who do you turn to for comfort when you're feeling down? Why?
tl
i 2. Is there any particular type of loss you think you would find hard to work with; death
i by suicide, murder, road accident, cancer, for example? With a partner, discuss why you
think this may be difficult.
i
3. Sit quietly by yourself. Let an image of death and/or dying come into your head. Does it
fi
have a size, a shape, colour, texture, smell? Does it change or remain the same? Is there
fi
anything else about it? When you feel you know your image, then draw, sculpt, make a
i
collage or write about it. Share with a partner.
g
* ¢

Further Reading

Gerhardt, Sue (2004) Why Love Matters: How Affection Shapes a Baby's Brain. London: Routledge.
She argues much of our brain and connections develop after birth, ready to be shaped and learn
from the environment we are born into.

Gersie, Alida (1991) Story Making in Bereavement: Dragons Fight in the Meadow. London: Jessica
Kingsley.
This is a lovely book which introduces stories connected to death which can be used therapeuti-
cally or just enjoyed.

Golding, Kim (2008) Nurturing Attachments: Supporting Children Who Are Fostered or Adopted.
London: Jessica Kingsley.
This book contains good descriptions of attachment types
 Bereavement 319

Mallon, B. (2011) Working with Bereaved Children and Young People. London: SAGE.
This is a comprehensive book which combines theory with practice and the latest research. Each
chapter ends with a reflective exercise which adds interest.

All About Me. This is a game (currently £45) developed by Barnardo's which is designed for use in
therapy to help children and young people talk about difficult feelings.

Pennells, M. and Smith, S. (1999) The Forgotten Mourners: Guidelines to Working with Bereaved
Children. 2nd edn. London: Jessica Kingsley.
Although quite an old resource, this book offers very practical and straightforward advice about
working with bereaved children and young people.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com.
 Depression
Caryl Sibbett and Cathy Bell

This chapter includes:

A
e Prevalence of depression
e Risk factors
e Interventions
e Counsellor’s practice
e Acase study
e Reflective activities
e Key resources

Introduction

Whilst this chapter focuses on depression it should be noted that linking factors with
self-harming and suicidality create significant overlaps with the ground covered in
Chapter 22. All such conditions and experiences are complex, and whilst they can
coincide and be inter-related, they each, including depression, may also occur indepen-
dently of each other and at the same time also be related to wider difficult experiences,
such as abuse, trauma, alcohol and drug problems, although again they may occur
independently of these.
 Depression 321

History and Background

Devaney et al. (2012: 51) note that ‘Shaffer et al. (1996) found that the majority of
young people who die by suicide have a mental illness, mostly depression. The World
Health Organization (WHO, 2013) reports that: ‘Mental disorders (particularly
depression and alcohol use disorders) are a major risk factor for suicide in Europe and
North America; however, in Asian countries impulsiveness plays an important role’
(see Chapter 22).
In counselling practice with such issues, duty of care to the client is of prime importance.
Especially when dealing with such an often resistant and hidden condition as depression,
the counsellor must always know, and practise within, their own professional boundaries
and take care of themselves as professionals. Counsellors should remember and use the
guidance and support available from their clinical supervisor and relevant professional
bodies and, when working in an organisation, from managers and colleagues.
As Bronfenbrenner (2005b: 262) concludes: ‘In order to develop normally, a child
needs the enduring, irrational involvement of one or more adults in care of and in joint
activity with that child. In short, somebody has to be crazy about that kid. Somebody
has to be there, and to be doing something - not alone but together with the child’
Specifically in counselling practice, the counsellor needs to ‘join with’ the client to ena-
ble them to ‘tell their story’ (Geldard and Geldard, 2009: 21).

Counselling and Depression

Experiencing different emotions is natural and feeling low or sad is part of a normal
response to life events that are upsetting or stressful. Generally, support and the pas-
sage of time help these feelings ease. However, in cases where a person feels very low
and sad and such feelings do not ease and tend to dominate and hinder usual activities
this can become an illness which is called ‘depression (Royal College of Psychiatrists,
2013). When a person has depression, they ‘feel very sad or down, and the feelings don't
go away or get worse. Depression is different from feeling a bit sad or down for a day or
two, which is how everyone feels from time to time’ (NICE, 2005: 7). Depression affects
a person's mood and they often also feel: ‘worried, tearful, moody, bored, tired most of
the time’ (NICE, 2005: 7). A young person with depression may also: ‘find it difficult to
concentrate; not want to see family and friends; have aches and pains; eat less or more
than usual; have problems sleeping; injure or hurt themselves; feel as if life is not worth
living’ (NICE, 2005: 7).
322 The Handbook of Counselling Children & Young People

Depression can be mild or more severe and the intervention should be tailored to the
level of depression and age of the child or young person (NICE, 2005).

Depression: Prevalence

The Mental Health Foundation (2013) summarises that: ‘One in ten children
between the ages of one and 15 has a mental health disorder’ (The Office for
National Statistics, Mental Health in Children and Young People in Great Britain,
2005). Estimates vary, but research suggests that 20 per cent of children have a men-
tal health problem in any given year, and about 10 per cent at any one time (Mental
Health Foundation, 2005).

Rates of mental health problems among children increase as they reach adolescence.
Disorders affect 10.4 per cent of boys aged 5-10, rising to 12.8 per cent of boys aged
11-15, and 5.9 per cent of girls aged 5-10, rising to 9.65 per cent of girls aged 11-15.
(National Statistics Online, 2004)

In its 2013 report, citing data for 2012-13, ChildLine (2013) stated that it created
a new category of ‘depression and unhappiness’ (including feeling sad, low mood,
lonely, low self-esteem, confidence or body image issues). ChildLine (2013: 56)
reports that:

In 2012/13, this new category was the top concern overall with 35,941 counselling ses-
sions about this issue as a main concern, and a further 51,918 where it was mentioned
as an additional concern — a total of 87,859 counselling sessions. This was also the top
concern for girls, and for young people aged 16-18 (where age was known).

Young people also talked about self-harming and feeling suicidal — both of which fea-
ture in the top five additional concerns where depression and unhappiness was the
main concern.

Depression: Risk Factors

Risk factors for depression in children and young people are complex and there is gen-
eral research consensus that there are multiple risk factors, both individual and social,
that are often not independent of each other (NICE, 2005: 50). There are likely to be
‘multiple risk pathways’ that may lead to depression (p. 51).
 Depression 323

These involve genetic predispositions, different types of adversities occurring during the
first two decades of life and acute personally disappointing life events not aconsequence
solely of past difficulties in the weeks prior to onset (Kendler et al., 2002). Adolescents at
high risk for depression are exposed to, or possess on average, three psychosocial risks in
the 12 months before follow-up (Goodyer et al., 2000b). (NICE, 2005: 51)

Children and young people can experience depression particularly as a response to

experiences like loss, family or school problems, family crisis or breakdown, major
changes in life circumstances. Depression seems to be associated with chemical changes
in the brain that affect mood control, and it may run in families (Royal College of
Psychiatrists, 2013). NICE (2005: 8) lists the following reasons why young people may
become depressed:

Being homeless, Being hurt at home, Being treated differently because of your race,
Bullying, Death of a parent, relative or someone close to you, Having other illnesses,
Moving away from your home country, Other members of your family being depressed,
Parents splitting up, School problems, Trouble at home, Friendships going wrong.

Depression can have physical causes and may also be a side effect of medication.
Counsellors need to be aware that depression may present in the sessions as physical
symptoms being described. It is important that the counsellor really listens to the client
and undertakes a comprehensive assessment.
Depression is more common in the teenage years than in children under 12 years of
age and it is more common in girls than in boys (Royal College of Psychiatrists, 2013).
Very high risk groups include: ‘looked-after children, refugees, the homeless and
asylum seekers. Children and adolescent offenders, particularly those in secure institu-
tions’ and those with a physical or learning disability (NICE, 2005: 51).

Depression: Interventions

Helping factors can include protective factors, self-help strategies, family and parental
support and education, social/environmental interventions, and psychological, phar-
macological and physical treatment (NICE, 2005).
Protective factors that ‘reduce the likelihood of depression in the presence of vul-
nerability and activating factors’ include: ‘a good sense of humour; positive friendship
networks; close relationship with one or more family member; socially valued personal
achievements; high normal intelligence’ (NICE, 2005: SVG)
As noted above, counselling interventions should be tailored to the level of depres-
sion and age of the child or young person and help provided should feature good
324 The Handbook of Counselling Children & Young People

information, a good relationship and advice about self-help strategies such as regular
exercise, balanced diet, ways of coping with sleep problems and anxiety, and relevant
treatment (NICE, 2005: 9-10).
Psychological approaches with children and young people affected by depression
tend to differ from those with adults, indeed:

children with depression are often not thought of as ‘having’ depression but as affected
by a set of emotional, behavioural, learning, relationship and family problems which
need to be considered together, and may still need to be addressed together, even if
depression in the child is a primary concern. (NICE, 2005: 75)

NICE (2005: 14) recommends the following psychological therapies for young people
with mild depression: non-directive supportive therapy, group cognitive-behavioural
therapy (CBT), guided self-help - if working, for two to three months; and for those
with more severe depression: individual cognitive-behavioural therapy (CBT), inter-
personal therapy, family therapy - if working, for at least three months.
A meta-analysis and review of evaluation and audit studies by Cooper (2009b: 2) of
counselling in UK secondary schools reports that school-based counselling was associ-
ated with large improvements in mental health (mean weighted effect size = 0.81), with
around 50 per cent of clinically distressed clients demonstrating clinical improvement.
Cooper (2009b: 33) notes that this is consistent with evidence that: ‘a non-directive
therapeutic intervention can be as effective as CBT for children and young people
experiencing mild to moderate depression (Birmaher et al., 2000; Vostanis, Feehan,
Grattan, & Bickerton, 1996).
Reporting on school-based counselling in UK secondary schools, Cooper (2013: 1)
notes that ‘non-directive supportive therapy is a NICE-recommended intervention for
mild depression; and there is emerging evidence to suggest that school-based human-
istic counselling — a distillation of common school-based counselling practices in the
UK - is effective at reducing psychological distress and helping young people achieve
their personal goals:
A NICE (2005: 95) report found that, while a range of therapy approaches have been
found to be effective by the end of therapy with reasonable follow-up benefit, mini-
mally treated children tend to catch up over time. NICE (2005) found inconclusive
evidence of the effectiveness of individual CBT, limited evidence of the efficacy of
interpersonal therapy (IPT), some unpublished evidence for benefits from individual
psychodynamic therapy, considerable evidence for effectiveness of group CBT with
adolescents, and unpublished evidence for effectiveness of family therapy.

Although little is known about therapist factors that influence outcome, there is some
evidence that professionally trained therapists have better results than paraprofessionals
 Depression 325

with this group. As there is some evidence that a positive treatment alliance predicts
better outcome, therapists who are better able to create this alliance with depressed
young people are likely to be more successful. (NICE, 2005: 98)

Giving guidance specifically for practitioners working with children and young people
experiencing depression, NICE (2005: 4) states:

Children and young people with depression should have the opportunity to make
informed decisions about their care and treatment, but this does depend on their
age and capacity to make decisions. It is good practice for healthcare professionals to
involve the young person's parent(s) or carer(s) in the decision-making process. Where
a child or young person is not old enough or does not have the capacity to make deci-
sions, healthcare professionals should follow the Department of Health’s advice on
consent and the code of practice that accompanies the Mental Capacity Act.

Psychological therapies, such as counselling and arts therapies, can be valuable inter-
ventions. For instance, family therapy, interpersonal therapy and CBT have been found
to be useful (Royal College of Psychiatrists, 2013). If depression is severe, then medi-
cation prescribed by a specialist medical professional can be useful (Royal College of
Psychiatrists, 2013). Devaney et al. (2012: 51) argue that:

There has been tremendous advancement in the treatment of adolescent depression

and many studies have assessed the use of CBT, interpersonal psychotherapy (IPT)
and medication (Jenkins, 2002; Scocco and De Leo, 2002; Conwell and Duberstein,
2001; Jenkins, 2002). A recent Cochrane systematic review of the research on psy-
chological and educational interventions for preventing depression in children and
adolescents (Merry et al., 2011, p.2) concluded that ‘Compared with no interven-
tion, psychological depression prevention programmes were effective in preventing
depression ... We found data to support both targeted and universal programmes,
which is important as universal programmes are likely to be easier to implement’

There is literature indicating that whilst group therapy can be valuable, as with all
forms of therapy, it may have risks if not managed appropriately. ‘Group therapy may
carry the risk of depression transmission, which may contribute to hopelessness, but
the therapist can mediate such negative dynamics, although this takes careful handling
(Winter et al., 2009: 35-6).
The BACP (2010a) notes that counselling for depression is ‘a manualised form of
psychological therapy as recommended by NICE’ (NICE, 2009) and:

It is based on a person-centred, experiential model and is particularly appropriate

for people with persistent sub-threshold depressive symptoms or mild to moderate
326 The Handbook of Counselling Children & Young People

depression. Clinical trials have shown this type of counselling to be effective when 6-10
sessions are offered. However, it is recognised that in more complex cases which show
benefit in the initial sessions, further improvement may be observed with additional
sessions up to the maximum number suggested for other NICE recommended thera-
pies such as CBT, that is, 20 sessions.

A stepped-care model indicates the diverse needs children and young people may have
depending on their circumstances and shows the services required at the various tiers,
ranging from risk-profiling to intensive care (NICE, 2005: 18-19). Counselling is part
of, and can be relevant across, all levels of a stepped-care model.
NICE (2005: 4) states that, when working with children and young people with
depression, practitioners ‘treatment and care should take into account the child’s or
young person's individual needs and preferences as well as the wishes of the parent(s)
or carer(s)
NICE (2005: 5) emphasises a number of key priorities for implementation, one of
which is that ‘psychological therapies used in the treatment of children and young people
should be provided by therapists who are also trained child and adolescent mental
healthcare professionals. During assessment, health-care practitioners should routinely
record:

potential comorbidities, and the social, educational and family context for the patient
and family members, including the quality of interpersonal relationships, both
between the patient and other family members and with their friends and peers.
(NICE, 2005: 5)

Practitioners should manage, in consultation with wider relevant social and edu-
cation care, any co-morbid conditions and developmental, social and educational
problems experienced by the child or young person and any parental mental health
needs.

Counsellors’ Practice

The literature on the topics of counselling for self-harm, suicide and depression indicate
that the counsellor’s practice should be evidence-based and should contribute effectively
to a holistic partnership approach and joint working strategy that is informed by rel-
evant current research, legislation and policy. Counsellors must also be mindful of their
organisational policies and protocols.
 Depression 327

Counsellors need to liaise appropriately with families and other professionals such
as CAMHS, school staff, GPs, social workers, etc. Support may be needed for other
individuals affected and the counsellor must be mindful of their limits and their role
in signposting and referring. Counsellors also need to be mindful of their personal
circumstances and the need to consult with their clinical supervisor and managers in
evaluating their fitness to work with individual cases. Counsellors have a role in being
a link to other agencies to facilitate referral.
Engaging in appropriate supervision is vital for all practice, and is particularly
useful in helping counsellors manage the ethical and emotional issues experienced
when working with children and young people who are experiencing suicidal
tendencies, self-harm and/or depression. In counselling and psychotherapy, it is
important to emphasise that the practitioner’s professional self-care is an ethical
imperative that is part of one’s duty of care to clients. It is vital that counsellors
working with such issues ‘consider their own self-care strategies, or lack of them.
Developing a plan of self-care can provide an important opportunity to model
an approach to self-care that clients might feel unable consider’ (Reeves and
Howdin, 2010: 5). Counsellors should practise in a way that demonstrates their
commitment to a relevant ethical code or framework, such as the BACP’s Ethical
Framework (BACP, 2013). The duty of care to clients is paramount and this also
includes appropriately addressing safeguarding relating to the welfare of children
and young people.
In general, counsellors’ practice should involve the appropriate management of
communication and informed consent. Gillick competence must be considered by
each counsellor. “Gillick competence is assessed to decide whether a child under 16
is able to consent to his or her own medical treatment without parental permission
or knowledge: a child should fully understand the medical treatment that is pro-
posed’ (NSPCC, 2009: 8). Organisational policies must also be considered by the
counsellor and this can include their employer organisation and a school context of
practice.
Counsellors should be aware of relevant protocols, procedures and best practice
when dealing with critical incidents. Some employing authorities may state that all
issues of self-harm or depression must be reported under safeguarding guidance. It
is a responsibility of the individual practitioner to make themselves aware of their
employer's stance. The client's welfare is paramount and counsellors may have to take
action in line with organisational policy that may mean the ending of the therapeutic
relationship.
Comprehensive assessment and the provision of co-ordinated care and services are
important. Practice should be provided in age/developmental appropriate ways and
with the use of interpreters as needed.
328 The Handbook of Counselling Children & Young People

Good practice in record-keeping has to be considered and implemented within

the context of the counsellor knowing agency expectations. It is necessary to ensure
that record-keeping is maintained with the awareness that, should there be sudden
death of a young client, the notes will probably be requested, for example in the
case of a child death review. Counsellors should adhere to good practice guid-
ance on record-keeping and information management, such as works by Bond and
Mitchels (2008).
In general, the management of endings and breaks must be handled according to
best practice. Whilst counsellors strive to provide a good enough secure attachment for
the client, breaks and endings can evoke feelings in the client and even in the counsellor
that can resonate with ambivalent or avoidant attachment experience (Ainsworth et al.,
1978) and these should be managed appropriately.
Counsellors should engage in routine evaluation, using appropriate outcome meas-
ures and audit tools as part of overall quality assurance. Counsellors’ practice, training
and supervision should also be informed by research. The following both exist in a
complementary relationship:

e Efficacy research: often referred to as evidence-based practice (EBP) (does it work?);

e Effectiveness research: often referred to as practice-based evidence (PBE) (does it work in
routine practice?)

Reporting on therapies and approaches for helping children and adolescents who
deliberately self-harm, SCIE (2005b) notes that both more EBP and PBE is needed,
particularly relating to younger children and on long-term effectiveness.
Counsellors can draw on a wide range of resources to inform their practice. The
Counselling MindEd initiative is ‘an evidence-based, e-Learning programme to support
training of school and youth counsellors and supervisors working in primary, second-
ary, tertiary and community settings, as well as the independent sector’ (Counselling
MindEd, 2013). Resources are available at http://counsellingminded.com/ and www.
rcpch.ac.uk/minded.
There is a growing literature on healthy schools initiatives, promoting emotional
intelligence and literacy and building resilience. Professional bodies such as the British
Association for Counselling and Psychotherapy (BACP) offer access to relevant spe-
cific interest groups such as the BACP Children and Young People division and the
Counselling Children and Young People Practice Research Network. The BACP has
developed a Competency Framework relevant for the 11+ age group and is considering
the development of one for younger children pre-11. The associated development of
curricula for the specialist training of counsellors to practise with children and young
people is also vital. Such projects will contribute to ensuring safe ethical practice in
counselling children and young people.
 Depression 329

Case Study Kevin

Kevin is 15. He is encouraged by his youth worker to attend counselling provided by acommunhity provider
with close links to the youth service and wider community activity. The youth worker has been worried
about Kevin self-harming as this previously has been his way of coping with changes or upsets in his life.
Kevin agrees to go for, in his words, ‘a checking out meeting with the counsellor’
It soon becomes obvious during this ‘checking out’ meeting that Kevin is deeply troubled, and
when he rolls up his sleeves because he ‘is too warm’, cuts are seen on both his arms.

Consider: How should the counsellor proceed?

Particularly consider:
What safeguarding issues are there and how can the counsellor manage them?
What ethical issues are there and how can the counsellor manage them?
Does the counsellor involve the youth worker?
For the counsellor, the young client’s welfare is the most important issue in that counselling/ther-
apeutic space. What are the implications for practice?
Joining with the young person is key to ensuring that their issues are allowed to surface in this
safe place. What are the implications for practice?
The counsellor has to be aware oftheir own situation and be conscious oftransference and coun-
ter-transference taking place. Is this serious self-harming, how often, using what, has the young
client thought of suicide, do they have a plan? What are the implications for practice?
What are the implications for practice in relation to Gillick competency, client autonomy, and risk
management?
What if the young person walks out, disengages, and what can a counsellor do in these situations?
How might it change implications for practice if the client was being seen in a school context?
How might it change implications for practice if the client was of another age, gender, culture,
ability, context, etc.? 5

Summary
SRL LD ASTROS ETD DEEL EEE SLED LEED LDOLE LE LESLIE LESS DLLEDIE IIL ELT LIDDELL LI LILLE EEBETO

In conclusion, in counselling with children and young people affected by such issues, it is important to:

e Provide a quality therapeutic relationship

e Listen to the young person's story, understandings and feelings
(Continued)
 330 The Handbook of Counselling Children & Young People

(Continued)

e Tailor the approach to the individual and contextual needs

e Adhere to best practice guidance and ethical principles
e Demonstrate evidence-based practice, showing relational competence and empathic
congruence
e Be informed by specialist training and supervision
e Engage in ongoing assessment, review, evaluation, quality assurance and continuing
professional development

Reflective Questions

1. In addition to a capacity to communicate respect, understanding and acceptance (Winter

et al., 2009), does research identify any other qualities, skills, competencies?
2. Some have suggested that depression might be due to changes in brain development in
adolescence. In addition, adolescents (particularly young women) have higher rates of
anxiety and depression than younger children, and self-harm is clearly associated with
these kinds of mental health problems (Hagell, 2013: 2). Does research identify any other
influencing factors?
3. Identify appropriate specialist training; utilise relevant outcome measures; identify rel-
evant legislation; consult recent research; discuss with your supervisor.

% ®

Learning Activities

1. Discuss and create a plan to ensure evidence-based practice.

2. Arrange an outreach programme to raise awareness in your community of the preva-
lence of depression in the child population and the available interventions.
3. It is important to give yourself attention. Explore ways of pacing yourself and your
energy output.
, — oe eee Y

Further Reading

Ainsworth, M.S., Blehar, M.C., Waters, E. and Wall, S. (1978) Patterns of Attachment. Hillsdale, NJ:
Erlbaum.
Geldard, K. and Geldard, D. (2009) Relationship Counselling for Children, Young People and Families.
London: SAGE.
 Depression 331

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com.
 Self-Harm and Suicide
Caryl Sibbett and Cathy Bell

This chapter includes:

EOE BSS LOOESSRUASELSGESSELIG SEDI ESIC STEED GEEEIEELIE SESELES SERVERS SLES ESSE LEE EEL LEEEESY

Self-harm and suicide as relevant to counsellors working with children and young people,
including:

e Prevalence
e Risk factors
e Interventions
e Reflective activities
e Key resources

Introduction: History and Background

As part of the UK context, ChildLine’s (2013) report Can I Tell You Something?, citing
data for 2012-13, indicates a significant increase in children and young people contact-
ing ChildLine for support on high-risk issues, with main concerns being: depression and
unhappiness (13%), family relationships (13%), bullying/online bullying (11%), self-
harm (8%), suicidality (5%), problems with friends (5%), physical abuse (5%), sexual
abuse (4%), puberty and sexual health (4%) and mental health issues (3%).
Hawton et al. (2012a: 2373) report that ‘Self-harm and suicide are major public
health problems in adolescents, with rates of self-harm being high in the teenage years
 Self-Harm and Suicide 333

and suicide being the second most common cause of death in young people worldwide.
Self-harm can be a suicidal act, but not everyone who self-harms is suicidal.
Suicide in adolescents ‘has been identified as a serious public health problem world-
wide (Devaney et al., 2012: 7), and a growing incidence of suicide has been reported
and high risk groups have been identified. For instance, young males generally are
associated with greater rick of suicide, particularly those aged 15-25 (Reeves and Seber,
2010:2):
The United Nations Convention on the Rights of the Child (UNCRC) puts a duty
of State parties to ensure that children and young people are supported during child-
hood so that they can attain the highest standard of well-being and health, and to
respond robustly where factors may impact on their welfare (Devaney et al., 2012: 7).
Counselling in schools is part of the response in the UK and Ireland. The UK Children’s
Commissioners and the UN Committee on the Rights of Children share a concern that
mental ill health and high rates of suicide and self-harm among children and young
people is one of the key areas of children’s rights that is being underplayed (Devaney
etral 5201237):
Government policy initiatives have aimed to promote suicide prevention and reduc-
tion, nationally and in the four UK countries, and an implication is that this should be
a priority for all therapists (Reeves and Seber, 2010). Often, such initiatives can be part
of wider well-being strategies.
When working with children and young people affected by such issues, it is vital that
the counsellor ensures the good quality of the therapeutic relationship. Counsellors
need to create positive therapeutic alliances with both the child or young person and
with their parents, and this is especially important since maintaining these over time
is predictive of successful treatment outcomes with youth (Shirk and Karver, 2010: 8).

Counselling and Self-Harm

It is important to note that self-harming is ‘not the core problem but a sign and symp-
tom of underlying emotional difficulties, used as a way of coping’ (MHF/CF, 2006,
cited in NSPCC, 2009: 3). The counsellor plays an important part in helping the client
explore the underlying emotional trauma that has led to the point of self-harming.
The National Institute for Clinical Excellence (NICE, 2004) guidelines define self-
harm as ‘self-poisoning or injury, irrespective of the apparent purpose of the act, and
adds that ‘self-harm is an expression of personal distress, not an illness, and there are
many varied reasons for a person to harm him or herself’ (NICE, 2004: 7). MIND
(2013c) states that ‘Self-harm is a way of expressing very deep distress. Often, people
don't know why they self-harm. It’s a means of communicating what can't be put into
words or even into thoughts:
334 The Handbook of Counselling Children & Young People

Self-harm is a broad term, often regarded as involving various specific behaviours

such as overdoses, self-mutilation, burning, hitting the head or other parts of the body
against walls, hair pulling, biting and/or reckless, risk-taking behaviour (National
CAMHS Support Service, 2011: 2). Self-harm has also been deemed to range across a
spectrum of activities from those causing immediate injury, to those where harm may
not be apparent for some years (Reeves and Howdin, 2010: 1), including addiction,
eating disorders, etc. (MIND, 2013c). Paracetamol overdose and cutting have been the
two most common forms of self-harm reported for children and young people, with
self-harm being more common after age 16 (SCIE, 2005b).
A recent study that examined epidemiology and characteristics of self-harm in ado-
lescents who attended hospital at sample sites in England reported that self-harm in
children and adolescents in England is common, especially in older adolescents, and
paracetamol overdose is the predominant method (Hawton et al., 2012b). Hawton et al.
(2012b: 369) found that relationship problems were the predominant difficulties asso-
ciated with self-harm.
Self-harming responses have diverse motivations and are generally a response to a
set of circumstances, rather than one isolated event (SCIE, 2005a). Self-harming may
help someone cope with intense feelings that seem overwhelming.

Self-harm may serve a number of purposes at the same time. It may be a way of getting
the pain out, of being distracted from it, of communicating feelings to somebody else,
and offinding comfort. It can also be a means of self-punishment or an attempt to gain
some control over life. Because they may feel ashamed, afraid, or worried about other
people's reactions, people who self-harm often conceal what they are doing rather than
draw attention to it. (MIND, 2013c)

Self-harming behaviour is primarily a coping strategy for young people (Hagell,

2013: 2) and can be experienced by the child or young person concerned as ‘sooth-
ing and relieving’ and, ‘As such, self-harm is an indication of a commitment to life
rather than wanting to die’ (Reeves and Howdin, 2010: 2). Some young people report
that self-harming can be soothing and injury can cause a release of endorphins that
gives a temporary sense of well-being (p. 2). However, it is important for counsellors
to note that:

People’s experience of self-harm is unique and provides sometimes contradictory

effects. For some people it is a confirmation of being alive, for some a distraction; for
some an external expression of internal turmoil whilst for others it is a visible com-
munication that they are struggling ... being open to explore with the person what
their behaviour might mean for them and what might be being communicated by it is
essential. (Reeves and Howdin, 2010: 2)
 Self-Harm and Suicide 335

Young people have reported that an obstacle to getting help is the fear that ‘self-harm,
the only coping strategy that had been keeping them going, might be taken away from
them’ (Richardson, 2012: 14). Therefore, young people need to be given support and
time to gradually develop more helpful and less risky coping skills (Richardson, 2012).
It is therefore important that self-harming be understood as a coping strategy, and
yet also that counsellors balance risk assessment with seeking to facilitate clients ‘over
time to find alternative, less self-destructive ways of caring for themselves’ (Reeves and
Howdin, 2010: 5). O'Connor et al. (2010: 2) note that ‘Irrespective of the motive(s) that
underpins the self-harm episode, it is important to recognise that adolescent self-harm
signals significant levels of current distress. Counsellors are in a unique position to
listen to the children and young people’s stories, help them manage their distress and
continue the journey with them to understanding what is happening and find new
positive ways of coping.
The NSPCC (2009: 5) summarises that: ‘In the majority of cases, self-harm appears
to be a way of coping rather than an attempt at destroying life: it is usually intended to
inflict harm rather than kill (MHF/CE, 2006). Choose Life (2012: 5) notes that ‘Self-
harm is generally a way of coping with overwhelming emotional distress. Many young
people self-harm where there is no suicidal intent. However, research shows that young
people who self-harm can be at a higher risk of suicide. MIND (2013c) comments that
‘The majority of people who self-harm are not suicidal, but a small minority will inten-
tionally attempt suicide. Therefore, counsellors should also be aware that significant
self-harm can have an associated risk of death and also a person can feel so distressed
or overwhelmed that their self-harm coping strategy can have the capacity to evoke sui-
cidal tendencies and behaviours. Overdosing is more likely to indicate suicidal intent,
as compared to cutting, ‘which tends to be a survival response to distress and depres-
sion’ (NSPCC, 2009: 5). Repeated self-harming is associated with risk of suicide (SCIE,
2005a).

Self-Harm: Prevalence

It has been reported that self-harming is prevalent and increasing and is the primary
issue that young people are concerned about among their peers (YoungMinds and
Cello, 2012: 14-15). Whilst it is difficult to ascertain accurate figures for the prevalence
of self-harm among children and young people, one national survey found that ‘the
prevalence among 5-10-year-olds was 0.8 per cent among children without any mental
health issues, but 6.2 per cent among those diagnosed with an anxiety disorder and
7.5 per cent if the child had a conduct, hyperkinetic or less common mental disorder’
(National CAMHS Support Service, 2011: 3, citing SCIE, 2005a). It was reported that
336 The Handbook of Counselling Children & Young People

this study also noted that ‘The figures increase dramatically for 11-15-year-olds, with
the prevalence of self-harm at 1.2 per cent among children without any mental health
issues, but 9.4 per cent among those diagnosed with an anxiety disorder, and 18.8 per
cent if the diagnosis is depression.
Although disclosures of self-harm have increased over the last decade, e.g. ChildLine
reported a 65 per cent increase between 2002 and 2004, a ‘heightened awareness of
the issue by both young people and professionals’ may explain some of the increase
(National CAMHS Support Service, 2011: 3). ChildLine’s (2013) report citing data for
2012/2013 indicates a 41 per cent year-on-year increase in young people talking about
self-harm, mostly (where age was known) in those aged between 12-15 years. ChildLine
(2013) also reports that it found a correlation between self-harming behaviours and
feeling suicidal: “During 2012/13, where suicide was the main reason for young people
contacting ChildLine, 34 per cent (4,993) also mentioned self-harm’ (p. 34).
Children and young people in Northern Ireland live in a context that is still experi-
encing the legacy of conflict and this has a negative impact on well-being. A report by
the Northern Ireland Commissioner for Children and Young people (NICCY, 2007)
states that children in Northern Ireland experience higher levels of suicide and abuse
than in the rest of the UK. However, a number of initiatives aim to reduce the impact
of the legacy of the conflict on psychological and emotional well-being in Northern
Ireland. For instance, the Department of Education's iMatter programme aims to pro-
mote pupils’ positive mental health and well-being, and the department funds the
Independent Counselling Service for Schools which provides access to professional
counselling support for young people in post-primary and special schools.

Self-Harm: Risk Factors

Research by O’Connor et al. (2010: 3) summarises that:

The CASE [Child and Adolescent Self-Harm in Europe] studies confirm past research
on clinical samples which suggest that the suicide and self-harm risk factors fall into
two main clusters: i) environmental or psychosocial factors which can be thought
of as external influences and adverse life events, and ii) psychological factors which
include personality and psychological characteristics (de Wilde, 2002). In addition,
both Hawton et al. (2002) and O'Connor et al. (2009) found evidence to suggest that
social influences, such as family and friends’ self-harm, are strongly associated with
adolescent self-harm.

Hagell (2013) summarises research that indicates a peak of self-harm in mid-adolescence.

Self-harming seems to be more prevalent in the following: older children and young
 Self-Harm and Suicide 337

people, in females and in Asian females, in young people in custodial settings, and in
those who have spent time in local authority care (NSPCC, 2009: 2-3).
The majority of those who engage in self-harm are young females compared to males,
although the figures for young men seem to be increasing (MIND, 2013c), and in particu-
lar, ‘the rate in young men aged 15-24 years is rising more quickly than in any other group’
(Royal College of Psychiatrists, 2010: 31). One study reported that ‘Four times as many
girls as boys self-harm up to age 16, although this ratio reduces to twice as many among 18
to 19 year-olds’ (SCIE, 2005a). However, ChildLine (2013) reports a 15:1 ratio of girls to
boys mentioning self-harm. In Northern Ireland, research indicates that ‘One in ten young
people reported that they had self-harmed at some stage in their lives with girls being 3%
times more likely to engage in self-harm than boys’ (O'Connor et al., 2010: 32).
MIND (2013c) cites research indicating that 10 per cent of 15-16-year-olds have
self-harmed, with such young people experiencing pressure within families, from
school and among peers and being more likely to have low self-esteem, be depressed
and anxious. Other risk factors include: mental health problems, dependency on drugs
or alcohol, major life problems, feelings of helplessness or powerlessness with regard
to their emotions (MIND, 2013c). Choose Life (2012: 10) summarises some identified
vulnerable ‘at risk’ groups:

adolescent females; young people in a residential setting; lesbian, gay and bisex-
ual and transgender people; young Asian women; children and young people in
isolated rural settings; children and young people who have a friend who self-
harms; groups of young people in some sub-cultures who self-harm; children and
young people who have experienced physical, emotional or sexual abuse during
childhood.

The counsellor again must always see the child and young person as an individual and
they may or not be part of one of these groups. Appropriate and comprehensive assess-
ment and ongoing review are of vital importance.

Indicators

Warning signs may not be obvious, because self-harming is usually a somewhat secre-
tive behaviour. However, they may include (Choose Life, 2012: 1):

e wearing long sleeves at inappropriate times;

e spending more time in the bathroom;
e unexplained cuts or bruises, burns or other injuries;
e razor blades, scissors, knives, plasters have disappeared;
e unexplained smell of Dettol, TCP, etc.;
e low mood - seems to be depressed or unhappy;
338 The Handbook of Counselling Children & Young People

e any mood changes - anger, sadness;

e negative life events that could have prompted these feelings - bereavement, abuse,
exam stress, parental divorce, etc.;
e low self-esteem;
e feelings of worthlessness;
e changes in eating or sleeping patterns;
e losing friendships;
e withdrawal from activities that used to be enjoyed;
e abuse of alcohol and or drugs;
e spending more time by themselves and becoming more private or defensive.

The diversity of indicators again indicates the importance of the counsellor using com-
prehensive assessment and ongoing review.

Self-Harm: Interventions

Whilst acknowledging that diverse terminologies, categorisations and perspectives

exist in relation to defining and working with self-harm, Reeves and Howdin (2010: 2)
emphasise that ‘Working with self-harm therapeutically is ultimately about creating
and maintaining therapeutic “contact” with the individual who finds self-harm to be
an important aspect of their experience, rather than pathologising their behaviour.
Tackling and reducing the stigma, guilt, shame, fear and mystery that can be asso-
ciated with self-harming by young people, parents and professionals is important
(YoungMinds and Cello, 2012: 9).
Interventions can include increasing knowledge and awareness raising, as well as
strategies to develop resilience and emotional literacy. “There is an urgent imperative
to build the emotional resilience of children and young people across society and
particularly in school’ (YoungMinds and Cello, 2012: 9), especially as part of a whole
school approach to promoting emotional health and well-being (YoungMinds and
Cello, 2012: 37; Connolly et al., 2011). It is important that such approaches to pro-
moting pupils’ emotional health and well-being are audited appropriately (Connolly
et al., 2011).
The Royal College of Psychiatrists (2010: 5) recommend that ‘the needs, care, well-
being and individual human dilemma of the person who harms themselves should
be at the heart of what we as clinicians do. When assessing those who self-harm, ‘it is
important to consider how intentional the behaviour is, the lethality of the action and
whether it is a one-off act or is something that a child or young person does frequently
over a period of time’ (National CAMHS Support Service, 2011: 2: 1.1). Assessment
should also include a full assessment of family and social situation and child protection
issues (NICE, 2011: 19).
 Self-Harm and Suicide 339

Counsellors should note that ‘It may also be valuable to investigate what happened
just prior to self-harming as this will enable an exploration of the intense emotions that
were managed through self-harm’. (Reeves and Howdin, 2010: 3)

Counsellors working with children and young people who are self-harming need to
take account of cultural aspects.

Cultural aspects will also be important defining factors in relation to self-harm, i.e. the
acceptability of behaviours will be defined as what is culturally and socially permissible.
... the meaning and context of the behaviour for the client will help clarify its commu-
nication. (Reeves and Howdin, 2010: 2)

Practitioners working with children and young people who disclose self-harming
have to manage various ethical aspects, as relevant to the age of clients. These include
negotiating confidentiality issues and consent for treatment and for the involvement
of parents and others and assessments should be underpinned by NICE Guidelines
and the Common Assessment Framework (NSPCC, 2009: 8). Counsellors need to be
aware of, and comply with, the legal requirements involved in working with children
and young people, such as when seeking consent for counselling. ‘Gillick competence is
assessed to decide whether a child under 16 is able to consent to his or her own medical
treatment without parental permission or knowledge: a child should fully understand
the medical treatment that is proposed’ (NSPCC, 2009: 8).
The NSPCC (2009: 8) summarises that

Types of therapeutic interventions mentioned in the MHF/CF report (2006) include:

e counselling that concentrates not on the injuries but the underlying problems that have
triggered the self-harm
e family therapy
e in-patient treatment e.g. in a specialist unit
e brief psychological therapy (problem-solving therapy)
e crisis cards (showing the card assures the holder of quick access to mental health workers
and admission to hospital in a crisis)
e behaviour therapy involving individual therapy.

A review commissioned by the National Institute for Health and Clinical Excellence
(NICE) for the purpose of developing clinical practice guidelines found that whilst
‘The evidence reviewed here suggests that there are surprisingly few specific interven-
tions for people who have self-harmed that have any positive effect ... the positive
outcome for adolescents who have repeatedly self-harmed receiving group therapy is
encouraging’ although it qualified this by stating that this research has limitations and
overall, more investigation is needed (NICE, 2004: 177-8).
340 The Handbook of Counselling Children & Young People

In a Report of the National Inquiry into Self-harm among Young People (Brophy,
2006: 11), one of the recommendations was:

Innovative approaches to prevention and intervention should be developed and evalu-

ated across the fields of health, education and social care. Counselling and peer support
schemes in schools, exercise on prescription and creative arts approaches all appear to
be worth taking further.

In the review questionnaire findings, when young people were asked what would be
helpful, the most popular response was ‘1:1 support/counselling’ (n = 121, 85%), fol-
lowed by responses including: ‘Group support/drop-im (n = 101, 71.1%), ‘Self-help
group (facilitated)’ (n = 86, 60.6%), ‘Creative initiatives’ (n = 85, 59.9%), ‘Multimedia/
internet access’ (n = 81, 57%) (p. 58).
When working with clients who engage in self-harming, it is important that the coun-
sellor can demonstrate relational competence, such as empathic congruence (Reeves
and Howdin, 2010: 3). Supervision and professional self-care are also vital when work-
ing with clients who engage in self-harming (Reeves and Howdin, 2010: 4-5).

Counselling and Suicide

Suicide is a ‘major public health issue’ that is ‘a devastating event for families and com-
munities’ (Scowcroft, 2013: 4). It has been described as a ‘multi-faceted phenomenon
involving the interaction between biological, psychological, sociological, environmen-
tal and cultural factors’ (Devaney et al., 2012: 7). Hawton et al. (2012a: 2373) note
that ‘important contributors to self-harm and suicide include genetic vulnerability
and psychiatric, psychological, familial, social, and cultural factors. The World Health
Organization (WHO, 2013) reports that: ‘Suicide is complex with psychological, social,
biological, cultural and environmental factors involved:
The term suicide refers to ‘deaths from both intentional self-harm and injury or
poisoning of undetermined intent’ (DH/Knowledge - Evidence and Analysis/Public
Health, 2012: 4). In 2011 England, Wales, Scotland and Northern Ireland adopted a
change in the classification of death statistics in line with the World Health Organization
(WHO) new coding rules which means that cases of self-injury/poisoning of ‘undeter-
mined intent’ are now classified as suicide (Scowcroft, 2013: 6).
Practitioners working with children and young people need to be aware that those
who are feeling suicidal may have mixed feelings such as wanting to die, wanting others
to understand how they are feeling, wanting help, etc., and such mixed emotions can be
confusing and cause more anxiety. Suicidal feelings often arise when we feel increased
hopelessness and worthlessness (MIND, 2013a).
 Self-Harm and Suicide 341

Suicide: Prevalence

Hawton et al. (2012a: 2375) report that ‘Globally, suicide is the most common cause of
death in female adolescents aged 15-19 years. The World Health Organization (WHO,
2013) reports that:

Every year, almost one million people die from suicide; a‘global’ mortality rate of 16 per
100,000, or one death every 40 seconds. In the last 45 years suicide rates have increased
by 60% worldwide. Suicide is among the three leading causes of death among those
aged 15-44 years in some countries, and the second leading cause of death in the
10-24 years age group; these figures do not include suicide attempts which are up to
20 times more frequent than completed suicide.

A systematic review of evidence summarised that ‘Suicide is the cause of death for
nearly 900,000 people every year. Non-fatal acts of self-harm are also very frequent,
occurring in about 300 of every 100,000 people per year, and although such acts may
or may not involve suicidal intent, deliberate self-harm is a significant risk factor for
eventual suicide (Winter et al., 2009: 4).
In the UK, ChildLine’s (2013) report citing data for 2012-13 indicates a 33 per cent
increase from the previous year in young people talking about suicidal thoughts and
feelings. ChildLine also reports that 60 per cent of its total referrals were about young
people who were actively suicidal (p.30). The Public Health Agency (PHA) noted that,
after a period of relatively static figures in the latter half of the last century, between
1999 and 2008 rates of suicide in Northern Ireland increased by 64 per cent and that
most of the rise was attributable to young men in the 15 to 34 age group (O'Hara, 2011).

Suicide: Risk Factors

Hawton et al. (2012a: 2375) summarise risk factors for self-harm and suicide in
adolescents:

Sociodemographic and educational factors

e Sex (female for self-harm and male for suicide)—most countries*

e Low socioeconomic status*
e Lesbian, gay, bisexual, or transgender sexual orientation
e Restricted educational achievement*

Individual negative life events and family adversity

342 The Handbook of Counselling Children & Young People

e Parental separation or divorce*

e Parental death”
e Adverse childhood experiences”
e History of physical or sexual abuse
e Parental mental disorder*
e Family history of suicidal behaviour*
e Marital or family discord
e Bullying
e Interpersonal difficulties*

Psychiatric and psychological factors

e Mental disorder*, especially depression, anxiety, attention deficit hyperactivity dis-

order
e Drug and alcohol misuse*
e Impulsivity
e Low self-esteem
e Poor social problem-solving
e Perfectionism
e Hopelessness*

All the factors in the panel have been shown to be related to self-harm.

*Shown to be related to suicide.

Devaney et al. (2012: 73) summarise research by Coleman and Hagell (2007: 14) and
note that:

The major risk factors for children tend to lie within chronic and transitional events,
rather than in acute risks. Therefore children show greater resilience when faced with
acute adversities such as bereavement, or short term illness, and less resilience when
exposed to chronic risks such as continuing family conflict, long term poverty, and mult
iple changes of home and school. The research highlighted in this report also confirms
that it is the multiplicity of chronic adversities which are the most dangerous for children
and young people.

Hawton et al. (2012a: 2373) note that: “The effects of media and contagion are also
important, with the internet having an important contemporary role’ In recent years,
the media have produced guidelines and revised policy on the reporting of self-harm.
For instance, “The UK Editors’ Codebook introduced a new rule for editors in 2006 that
when reporting suicide, care should be taken to avoid excessive detail of the method
used’ (Royal College of Psychiatrists, 2010: 53). It has been noted that ‘One in five
schoolchildren with a history of self-harming questioned by researchers said they first
 Self-Harm and Suicide 343

learnt about it after seeing or reading something online, second only to hearing about it
from friends’ (Royal College of Psychiatrists, 2010: 52-3). Counsellors should be aware
of the risks and benefits of media and internet influences and resources.
A report on UK suicide statistics by the Samaritans (Scowcroft, 2013) indicates that
the suicide rate for young males is higher than that of young females. Young males gen-
erally are associated with greater rick of suicide, particularly those aged 15-25 (Reeves
and Seber, 2010: 2). As well as young men, looked-after children and young people
who are misusing drugs or alcohol are at risk of death by suicide and the latter ‘can be
particularly vulnerable in the “come down” phase’ (Choose Life, 2012: 17).
Other risk factors for children and young people include: mental health problems,
previous suicide attempts, having a relative or friend who has attempted or completed
suicide, having been in a young offenders institution/prison, recent bereavement, recent
loss of employment, in an isolated or rural community, homeless (Choose Life, 2012: 17).
Other general risk factors include: social isolation, a history of sexual/physical abuse,
one of various psychiatric illnesses including depression, prior attempts/history of sui-
cide and in family, unemployed, specific plan formulated, and single (Reeves and Seber,
2010: 2; Reeves et al., 2003; Ruddell and Curwen, 2002). Repeated self-harming is asso-
ciated with risk of suicide (SCIE, 2005a).
Whilst factors contributing to suicidal behaviour are multiple, complex and both
personal and social, ‘It is possible that when one decides to commit suicide, he/she may
select one of the options available to make the act more socially and personally accept-
able, and one of these may be alcohol’ (Pompili et al., 2010: 1407).
In severe forms, major/clinical depression can be life-threatening (MIND, 2013b).
However, counsellors should note that MIND (2013b) notes that people are more vul-
nerable to acting on suicidal thoughts as they start to come out of depression, rather
than when it is at its most severe, possibly because people ‘have more energy and moti-
vation available at that stage.
Hawton et al. (2012a: 2373) summarise that:

Major challenges include the development ofgreater understanding of the factors that
contribute to self-harm and suicide in young people, especially mechanisms under
lying contagion and the effect of new media. The identification of successful prevention
initiatives aimed at young people and those at especially high risk, and the establish-
ment of effective treatments for those who self-harm, are paramount needs.

Suicide: Interventions

In a review of the evidence, it has been reported that interventions to prevent suicide
and self-harm are diverse and offered across a range of levels and settings (Macdonald
et al., 2012).
344 The Handbook of Counselling Children & Young People

Effective intervention is characterised by a systemic approach that takes seri-

ous consideration of the individual child or young person’s developmental context
(Daniel and Goldston, 2009), cultural context (Joe et al., 2008; Goldston et al.,
2008) and social context (Burrows and Laflamme, 2010). A systemic approach
also aims to offer interventions organised across relevant levels, and such models
include providing:

e preventative measures, early intervention, and interventions that focus on those who
are engaging in self-harming or suicidal behaviour (Macdonald et al., 2012: 140) and
rehabilitation (after a child is in state care and/or has complex and enduring needs)
(Hardiker et al., 1991) such as is implemented in children’s services in Northern Ireland
(Devaney et al., 2012: 49);
e whole school/community interventions, targeting specific high-risk groups, and
focusing on those showing early signs of self-harming or suicidal behaviour
(Nordentoft, 2007);
e individual measures (e.g. counselling) and structural measures (restricting means,
addressing social exclusion) (Nordentoft, 2007);

Hawton et al. (2012a: 2373) note that

Prevention of self-harm and suicide needs both universal measures aimed at young
people in general and targeted initiatives focused on high-risk groups. There is little
evidence of effectiveness of either psychosocial or pharmacological treatment, with
particular controversy surrounding the usefulness of antidepressants. Restriction of
access to means for suicide is important.

Devaney et al. (2012: 50) note that:

Arensman (2010) concluded that interventions with the best evidence for suicide pre-
vention include:

e means restriction, including identification of ‘hotspots’;

e clinical guidelines for all health and social services staff to use when dealing with
people who are at risk of suicide/self-harm; and
© programmes that enhance the coping and problem-solving skills of those who self-
harm, and which reduce the risk of repeat self-harm.

Counsellors should engage in assessing risk for suicide and self-harm and, as with all
practice, this should be informed by the use of appropriate risk assessment tools and
routine outcome evaluation. Age and ability relevant measures should be implemented
and this should include outcome measures and therapeutic alliance measures; for
 Self-Harm and Suicide 345

instance using outcome and session rating scales (Duncan and Miller, 2008). In child
and adolescent therapy, “Therapists are advised to monitor alliance over the course
of treatment’ (Shirk and Karver, 2010: 8). The BACP’s Children and Young People
Practice Research Network (CYP PRN, 2013) published A Toolkit for Collecting Routine
Outcome Measures that offers information and resources relating to evaluation and the
collection of routine outcome data.
Counsellors may also be involved in appropriate post-vention responses (Choose
Life, 2012: 19), for instance as part of a comprehensive community response (Forbes
eral 22012):
Counsellors should be research-informed in their practice and differentiate between
evidence and myths. ‘We need to be able to speak about suicide with children and young
people and to dispel myths for all concerned’ (Care Inspectorate, 2011: 3). Reeves and
Seber (2010: 2) state that:

There is no evidence that asking clients whether they have suicidal thoughts will put
the thought into their mind if it was not there before. There is, however, a great deal
of evidence to suggest that being able to talk to clients about suicide is extremely
important in providing a safe space for themto explore their feelings.

NICE (2005) recommends that professionals should follow advice on consent in local
legislation and government guidelines.
Devaney et al. (2012: 50) summarise that Crowley et al. (2004):

provided a review of suicide prevention strategies specifically for young people:

Curriculum-based suicide prevention programmes; recognition, management and

prevention of youth suicidal behaviour by primary care practitioners; interventions
targeting family risk factors; suicide prevention programmes for at-risk groups; poten-
tial points of access to those contemplating suicide; prevention of access to means;
media restrictions; and psychosocial and pharmacological treatments for deliberate
self-harm.

Hawton et al. (2012a: 2378) summarise approaches to prevent self-harm and suicide in
adolescents:

Population measures

e School-based psychological well-being and skills training programmes

e Gatekeeper training (e.g., school teachers, peers)
e Screening to identify those who might be at risk
e Restriction of access to means used for self-harm and suicide
346 The Handbook of Counselling Children & Young People

e Improved media reporting and portrayal of suicidal behaviour

e Encouragement of help-seeking behaviour
e Public awareness campaigns
e Help-lines
e Internet sources of help
e Reduction of stigma associated with mental health problems and help seeking

Measures for at-risk populations

e Psychosocial interventions for adolescents at risk of self-harm or suicide (e.g.

depressed adolescents, abused individuals, runaway children)
e Screening of those at risk (e.g., young offenders)
e Psychosocial interventions for adolescents who have self-harmed
e Pharmacotherapeutic interventions for adolescents at risk of self-harm or suicide.

A Scottish practice guide on suicide prevention for looked-after children and

young people (Care Inspectorate, 2011: 32) notes the importance of a ‘partner-
ship approach to protecting children and young people where at all possible from
attempting or completing suicide. This involves engaging and developing the
young person's inner resources and supporting these by effective joint working and
appropriate communication.
Building resilience is seen as one key factor in helping those engaging in self-harm
(National CAMHS Support Service, 2011: .9: 4.1). A recent General Comment from
the Committee on the Rights of the Child (2011: 26) states: ‘It is of critical importance
to understand resilience and protective factors, i.e. internal and external strengths and
supports which promote personal security and reduce abuse and neglect and their
negative impact. Joiner et al. (2001) suggest that problem-solving treatment benefits
suicidal young adults with comorbid depressive and anxiety disorders.
Supervision and professional self-care are vital when working with suicidal clients
(Reeves and Seber, 2010: 5) and can help manage the effects of vicarious stress or trau-
matic reaction.
There are strategies, such as in England (HMG/DH, 2012), that aim to help in the
prevention of suicide. These note the need to contribute to prevention by addressing
the need to (HMG/DH, 2012):

e reduce suicide risk in high-risk groups such as young men and those with mental health
problems, with a history of self-harm, and in contact with the criminal justice system;
e improve mental health and weil-being, including of children and young people, looked-
after children, those in the youth justice system, survivors of abuse or violence, ethnic
minorities, etc.;
 Self-Harm and Suicide 347

¢ address problems such as bullying, poor body image, low self-esteem, etc.:
¢ create safer online environments, including ‘Recognising concern about misuse of the
internet to promote suicide and suicide methods, we will be pressing to ensure that
parents have the tools to ensure that their children are not accessing harmful suicide-
related content online’ (HMG/DH, 2012: 8: 34)

Online resources are available, such as the Department of Health’s e-portal which
includes ‘specific learning and professional development in relation to self-harm, sui-
cide and risk in children and young people’ (HMG/DH, 2012: 24: 2.15).
Whitlock (2010) summarises a systematic review (Hawton et al., 1999) of 23 ran-
domised controlled trials related to deliberate self-harm in which reviewers ‘concluded
that the most promising approaches include problem-solving therapy, provision of
emergency service contact information, long-term psychological therapy’ and phar-
macological treatment where appropriate.
A meta-synthesis of research (Winter et al., 2009) identified a number of themes
with regard to views held concerning the process of counselling or psychotherapy relat-
ing to the prevention of suicide:

e Therapeutic relationship: indicated as important in quantitative and qualitative studies.

e Therapist qualities: communicating respect, understanding and being non-judgmental,
were reported by clients to be important.
e Therapy components:
o Duration: in general, clients seemed to report that therapy sessions and duration were
sometimes too short.
o Noself-harm contracts: clients’ views on the value of no self-harm contracts were mixed,
and counsellors in general seemed to endorse the inappropriateness of such contracts —
although both varied across theoretical modality. In insight oriented counselling, such
contracts tended to be viewed as problematic, whilst in dialectical behaviour therapy
(DBT), such contracts tended to be viewed as ‘an effective way of reducing the ther-
apist’s anxiety to allow them to focus on teaching the skills to alleviate self-harming
behaviour’ (Winter et al., 2009: 45).
e Theoretical framework: working within a coherent theoretical framework.
e Therapy techniques: group, skills training, telephone coaching.

Key recommendations of the review by Winter et al. (2009: 55) are that:

e People at risk of suicide should have access to psychological interventions, including

those within the cognitive-behavioural spectrum.
e Therapies for which there have been promising findings, but which are under-researched,
should be a research priority.
 348 The Handbook of Counselling Children & Young People

e Psychotherapists, counsellors and other staff working with clients at risk of suicide
should be provided with specific training and support systems in relation to this work.

Counsellors can inform their practice by noting that Devaney et al. (2012: 51) sum-
marise that:

The key message from the research on the effectiveness of suicide prevention inter-
ventions is that there are a range of evidence-based approaches but there is no magic
bullet or one size fits all approach as interventions are needed across the different levels,
tiers or steps and across all aspects of life including parenting, education, employment,
health and social care.

Case Study Terry

Terry is 14. He is encouraged by his teacher to attend counselling on the school site which is linked
with a family support service. The teacher is concerned that Terry has recently become very with-
drawn since his brother's death in a road accident. When approached, he said he ‘didn’t see much
point in going on now‘ Terry agrees to meet the counsellor ‘just to see ...!

Consider: How should the counsellor proceed?

Particularly consider:
What safeguarding issues are there and how can the counsellor manage them?
What ethical issues are there and how can the counsellor manage them?
Does the counsellor involve the teacher?
For the counsellor, the young client's welfare is the most important issue in that counselling/thera-
peutic space. What are the implications for practice?
Joining with the young person is key to ensuring that their issues are allowed to surface in this safe
place. What are the implications for practice?
The counsellor has to be aware of their own situation and be conscious of transference/counter-
transference taking place. Is the young client thinking of suicide, do they have a plan? What are the
implications for practice?

What are the implications for practice in relation to Gillick competency, client autonomy, and risk
management?

What if the young person walks out, disengages, and what can a counsellor do in these situations?
 Self-Harm and Suicide 349

How might it change implications for practice if the client was being seen in the community?

How might it change implications for practice if the client was of another age, gender, culture,
ability, context, etc.?

Summary

Key implications for practitioners undertaking this work with children and young people include
the need to:

e de-stigmatise self-harm and suicidality and dismantle misconceptions

e respect confidentiality and young people's wishes
e set the right priorities, such as minimising harm; rather than focusing on stopping it altogether
without support and without establishing other coping mechanisms
e actin accordance with current law and codes of practice
e have appropriate ongoing training and supervision
e engage in early prevention and promotion of mental health, particularly in schools. (NSPCC,
2009: 12-15)

Reflective Questions

1. What therapist qualities are identified by clients as being important in the process of coun-
selling children and young people who are suicidal/self-harming?
2. Why is self-harming more prevalent in adolescence?
3. What continuing professional development do you need in this area and what is your CPD
plan of action, including identifying research, legislation and key learning that can inform
your practice?

Se a ee,
®
Learning Activities

1. As an individual or team consider what Gillick competency means in your practice,

taking into account your contextual situation.
2. Critically evaluate some ethical issues you might encounter.
3. Identify ways of managing these, including appropriate consultation and the use of
ethical frameworks and decision-making models.
®
¢
350 The Handbook of Counselling Children & Young People

Further Reading

NICE (2011) Self-Harm: Longer-Term Management. NICE Clinical Guideline 133. London: NICE.
Available at: www.nice.org.uk/nicemedia/live/13619/57179/57179.pdf.
Royal College of Psychiatrists (2010) Self-Harm, Suicide and Risk: Helping People Who Self-Harm:
Final Report of aWorking Group. College Report CR158. Available at: www.rcpsych.ac.uk/files/
pdfversion/cr158.pdf.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People,
Counselling MindEd: http://counsellingminded.com.
 Sexual, Physical and Emotional
Abuse
Beverly Turner-Daly

This chapter includes:

e A brief summary of the evidence base and an outline of the general principles of working
therapeutically with children who have been abused
e An overview of the legal and policy context, especially in relation to confidentiality, infor-
mation-sharing and differing roles and responsibilities and how this fits within the wider
‘safeguarding children’ agenda
e An in-depth account of the effect of abuse on a child’s sense of self, explored within a case
study drawing on the author's clinical experience

Introduction

Children who have been abused experience a wide range of emotional and behavioural
difficulties which sometimes result in them being referred for counselling or therapy
(Allnock and Hynes, 2012; Daniels and Jenkins, 2010; Geldard et al., 2013). The effects
of abuse are different for each child but in some instances, they can be enduring, lasting
into adult life and impacting significantly on mental health, relationships and well-
being (Davidson et al., 2010; Pritchard, 2013). Empirical studies into the efficacy of
therapeutic interventions are limited due to the significant ethical and methodological
352 The Handbook of Counselling Children & Young People

challenges posed (Mudaly and Goddard, 2009); nevertheless, research in this field is
progressing and it has been suggested that we are moving towards a clearer under-
standing of the respective merits of different forms of intervention (Myers, 201 I);
Some aspects of this chapter overlap with Chapter 17, “Law and Policy, which pro-
vides important foundation knowledge, consolidated upon here. Both chapters stand
alone, however if you choose to read them together, it is recommended that you read
Chapter 17 first.

Note of Caution

The case study in this chapter is fictitious but inspired by the stories of many children
with whom the author has had direct or indirect contact. It has been designed to bring to
life the impact of child abuse and, as such, has potential to cause distress to some readers.

General Principles for Working Therapeutically with Children

Affected by Abuse

Working with children who have been abused can be daunting, and it would help thera-
pists enormously to have access to evidence about which approaches are most effective
in which circumstances. Although there is an extensive research base relating to the
long-term effects of abuse on children (Cashmore and Shackel, 2013) and evidence-
informed clinical excellence guidelines exist relating to specific psychiatric disorders
(NICE, 2005) the comparative value of the wide range of treatment interventions on
offer is still being explored (Myers, 2011).
Amongst the interventions available to counsellors are play therapy (directive and
nondirective), systemic family therapy, group work and cognitive-behavioural therapy.
Exponents of the latter have led the way in establishing an evidence base and research
suggests that cognitive-behavioural therapy is particularly effective in reducing symp-
toms of post-traumatic stress disorder in children who have been abused (Deblinger
et al., 2006). However, until more research becomes available, it would be unwise to
rule out ‘unproven interventions and more helpful perhaps, to think in terms of key
therapeutic principles that give rise to a range of possibilities. These principles are:

e Pre-requisites to working with children who have been abused

e Avoidance of ‘labelling’
e Listening to children
e Managing the legal process in the best interests of the child.
 Sexual, Physical and Emotional Abuse 353

Prerequisites to Working with Children Who Have Been Abused

There are several prerequisites to the provision of counselling and therapy for children
and young people who have been abused. Firstly, the client ought to be living in a safe,
secure environment where his/her physical and emotional needs are being met (Doyle,
2012). Supportive carers make strong allies and can have a significant impact on out-
comes of therapeutic work (Sgroi, 1982). Consideration must be given to how therapy
may affect ongoing legal proceedings; an issue explored in more detail elsewhere in
this chapter and in Chapter 17. In the most appropriate way, children should be con-
sulted about therapeutic options and their wishes and feelings taken into account.
Empowerment is central to all interventions with children who have been abused.
Some children are reluctant to attend counselling sessions (Spratt and Devaney, 2009),
therefore careful thought should be given to the extent to which children are pressur-
ised into attending against their wishes. Consideration should also be given to what
else is happening in the child’s life at the point of referral so that the timing of interven-
tion is compatible with other priorities such as relationships, education and home-life
(Bannister et al., 1990). ;
Given that resources are scarce and, in some areas, children have limited access to
counselling, care must be taken to ensure the timing is right. A child may be afforded
only one opportunity for therapy therefore it is essential that this is not wasted.

Labelling

Devastating though it may be, we must remember that abuse is an experience, one
aspect of a child’s life. Therapists and other professionals must take care not to con-
tribute to any process through which abuse becomes part of a child’s identity. Children
who have been abused may find the labels ‘victim’ or ‘abused child’ hugely stigmatis-
ing (Bass and Davis, 2008). Abuse can be seriously damaging to a child's self-esteem
and sense of identity (Sanford, 1991) therefore counsellors, therapists and other profes-
sionals can make an important therapeutic intervention simply by being careful not to
label. By seeing beyond the abuse and emphasising that the child is so much more than
their abusive experience, counsellors can begin the process of helping children to move
forward. Language is vitally important in this regard. We might deliberately choose
to talk about ‘a child who has been abused’ rather than an ‘abused child’ or ‘victim of
abuse, We might challenge assumptions that all children who have been abused need
therapy or that all children who have been abused are in some way damaged. It is not
uncommon for children who have experienced abuse in its various forms to feel angry,
hurt, betrayed, ashamed, guilty, frightened, sad, unlovable, unworthy and culpable,
354 The Handbook of Counselling Children & Young People

however this is not universal (Browne and Finkelhor, 1986). Labels are rarely helpful to
anyone. In the case of child abuse, labels may reinforce the negative experiences and act
as barriers to recovery and we should avoid them.

Listening to Children

By listening very carefully and being mindful not to judge, counsellors can empower
children and lay positive foundations for future work. This is equally important
whether we are involved in a counselling relationship or in any other capacity. In this
author’s experience, professionals sometimes recommend and advocate strongly for
children to receive therapy even when there are indications that the child is not ready
for this. Child abuse can make caring adults feel incredibly responsible, sometimes
‘duty-bound’ to do something to compensate for the harm caused by others. Pushing
for a child to receive therapy can be part of this process. Sometimes, when considering
the suitability of counselling or therapy for a child who has been abused, it is important
to step back, reflect on our feelings and examine carefully, whose needs we are trying
to meet.
The ‘child protection system, with its emphasis on gathering information and pre-
venting further abuse, can at times be disempowering to children. Children may be
worried about the consequences of telling and become overwhelmed by the impact
of professional involvement in their lives. This may shed light on why so many chil-
dren report abuse only to retract later, although research is needed to substantiate this
hypothesis. Abuse can give rise to conflicting and ambivalent feelings (Browne and
Finkelhor, 1986). Professionals may assume that thoughts and feelings relating to abuse
will be uppermost in a child’s mind when in fact for some, home life, hobbies, friend-
ships and day to day stuff of life might matter more. It could be suggested that on
occasion, the best intervention a professional can make is to recognise that therapy can
go on hold in the short-term whilst focus is placed on supporting the child to re-adjust
to post-abuse life, whatever that may involve.

Managing the Legal Process in the Best Interests of the Child

Counselling children who have been abused is particularly complex because often, not
only are such children clients but they are simultaneously witnesses to a crime and, as
such, may be required to give evidence in legal proceedings against the perpetrators
of their abuse. In these situations, the therapeutic needs of individual children may be
 Sexual, Physical and Emotional Abuse 355

viewed by some professionals as secondary to the task of securing a conviction, thus

protecting other children from harm. Counsellors who work in the field of child abuse
need to be familiar with the legal and policy context of their work so that they are best
placed to contribute to decision-making with regard to timing and nature of therapeu-
tic interventions. The legal and policy context of counselling children who have been
abused is explored below. If you have not done so already, you may find it helpful to
read Chapter 17 before continuing.

Legal and Policy Overview

Comprehensive statutory guidance exists to help UK professionals understand their

responsibilities in relation to safeguarding children. This guidance, contained in the
document ‘Working Together to Safeguard Children’ (DfE, 2013) is regularly updated
and regarded as essential reading for all practitioners whose work brings them into
contact with children and young people who may have experienced physical, sexual,
emotional abuse or neglect. “Working Together’ makes clear that all professionals have
a responsibility to share safeguarding concerns (usually with the local authority or the
police) and emphasises that in cases where a child may be at risk of ‘significant harm,
this overrides any duty of confidentiality a professional may have towards a child. As
the title of the guidance suggests, an objective of this guidance is to strengthen inter-
professional communication and reduce the risk of child abuse going undetected or
unreported. For over 30 years, inquiries into child deaths and ‘serious case reviews’
have consistently highlighted weaknesses in professionals’ ability to recognise indica-
tors of abuse, exchange information and take effective action to protect children. By
updating and clarifying legal and policy terms, defining different forms of abuse and
recommending structures to support information sharing, the government, through
‘Working Together, makes explicit its expectations of all practitioners who work with
children and young people. This document, in addition to local safeguarding children
board (LSCB) policies and procedures and a clear working knowledge of appropriate
professional codes of practice, should provide counsellors with a good understanding
of their role and responsibilities in relation to safeguarding children. Many counsellors
find it helpful to supplement this knowledge by attending ‘Child Protection Awareness’
training offered locally by most LSCBs, where they can discuss tensions and dilemmas
with other professionals and reflect on their role in this complex area of practice.
There are, without doubt, some tensions between ‘child protection’ and counselling/
therapeutic work and despite guidance and training, knowing what to refer on is not
always clear cut. ‘Significant harm’ is a subjective term and safeguarding children is a
complex task, characterised by uncertainty and ethical dilemmas. Despite guidance
356 The Handbook of Counselling Children & Young People

contained in codes of practice (BACP, 2010b) this issue is one that is often brought to
supervision, where the ‘policeman’ function is often in evidence and is a space where
ethical dilemmas can be explored (see Chapter 13: ‘Supervision’). Counsellors should
never be afraid to voice concerns about real or potential child abuse. Reflection, criti-
cal analysis and soul-searching usually results in safer professional judgements being
made. Children who are/have been abused deserve nothing less.
Although statutory guidance suggests that neither the police nor Crown Prosecution
Service should seek to prevent therapy from taking place prior to a trial (Crown
Prosecution Service, 2001) in practice there can be disagreement as to whether therapy
is appropriate and if so, when. It should also be remembered that often, children dis-
close abuse during the process of therapy or make additional ‘fresh allegations’ that
have to be shared. There may be occasions where there appears to be a contradiction
between what the child needs and what is needed of the child which may give rise to
tensions between the various adults involved. Good working relationships, negotiation
and effective planning in the best interests of the child are essential in these circum-
stances, as is remembering to consult the child and ensure their wishes and feelings are
included in decision-making.
Issues relating to pre-trial therapy are outlined in Crown Prosecution Service guid-
ance; essential reading for counsellors who work with children (Crown Prosecution
Service, 2001). Whilst making clear that the best interests of the victim must come
first, potential pitfalls of pre-trial therapy are recognised and highlighted. A key issue
is the extent to which therapy may be construed as ‘contaminating’ a child’s evidence
and used to undermine the chances of a successful conviction. Where a child has
received therapy prior to giving evidence in court, lawyers acting for the defendant(s)
may question reliability, suggesting that talking about experiences can interfere with
accurate recall. Group therapy is particularly problematic in terms of legal proceed-
ings as children and young people hear about the abuse of others and it may be argued
that personal experiences become muddled with those of others. The younger/more
impressionable the child, the more problematic this becomes. Although steps are taken
to shield children from the most intimidating aspects of giving evidence in court (pre-
recorded evidence, video-links and informal dress) children are nevertheless subject to
vigorous cross-examination; a process through which a child’s true experiences can be
made to appear false. When a child goes through the ordeal of giving evidence in court
and the outcome is acquittal, the impact on the child can be devastating. Nothing can
compensate for the message this gives to the child. Since not being believed is one of
the most common strategies abusers use to silence their victims, a ‘not guilty verdict’
reinforces the power of the abuser and usually has a significant impact on the child’s
recovery process.
The problems associated with fair and ethical prosecution of child sexual abuse cases
are well documented. At the time of writing, a consultation process is underway on new
 Sexual, Physical and Emotional Abuse 357

government guidelines (Crown Prosecution Service, 2013) issued following the high
profile prosecution of several cases of child sexual exploitation. These interim guide-
lines suggest that where therapy is carried out in accordance with statutory guidance,
therapy should not interfere with a subsequent trial, therefore where needed, pre-trial
therapy or counselling should not be withheld. This guidance should strengthen the
hand of counsellors who may at times have to make the case for prompt therapy, for
example, where a child is showing acute signs of distress or where a delay to therapy
may jeopardise a good placement. In other situations, where there is a real risk that the
therapy may be used against the child, a case may be made for delaying therapy until
criminal proceedings are over.
In all matters relating to safeguarding children, child-centred practice and good
working relationships between professionals is fundamental to successful outcomes. In
ways appropriate to their level of understanding, children and young people should be
consulted in decisions about therapy and their opinions genuinely listened to. Despite
the confidentiality that forms the basis of all therapeutic relationships, it is still possible
for counsellors to work in partnership with children, carers and professionals to share
whatever information is relevant and negotiate how best to help the child. Skilfully
navigating around ethical dilemmas and avoiding polarisation or professional splitting
is an essential part of a therapist’s role in this area of work.

Evidence-Informed Practice

At the time of writing, a discourse of ‘evidence-informed practice’ is widespread,

underpinned by government expectation that clinical interventions should be
informed by appropriate theory and research, especially in relation to efficacy. This is
more complex than it may seem. One position is that it is possible through research to
demonstrate the effectiveness of some forms of therapeutic intervention in the same
way one might measure the effectiveness of a drug. An alternative position is to ques-
tion the reliability of the science behind such research and suggest that in a challenging
economic climate, there is an inherent bias in favour of short-term, comparatively
cheap methods. Counsellors need to be aware of current theory and research but be
critical consumers of knowledge; exploring origins, considering ethical issues and
measuring published findings against their own practice wisdom and experience. The
effects of child abuse and choices of therapeutic intervention are inextricably linked
however in our quest for evidence-informed practice, we must be aware of the risks
of over-generalising.
Humans are infinitely complex; the unique ‘product’ of what they bring into the
world and what is experienced from then on in. How each child or young person is
358 The Handbook of Counselling Children & Young People

affected by abuse is unique. Factors considered relevant include: nature and duration of
the abuse, relationship to abuser, age, gender, physical and emotional maturity, culture,
ethnicity and race (Cashmore and Shackel, 2013; Myers, 2011). There is much debate
about core concepts such as attachment theory, vulnerability and resilience (Howe,
2005) although it has long been asserted that the quality of relationships with non-
abusing significant adults is highly significant in outcomes for children (Wyatt and
Powell, 1988). Given the complex interplay of a huge number of variables, counsellors
need to be cautious in their use of theory and research and true to the principle of treat-
ing each client as an individual in their own right.
Whether they work with children, adults or both, counsellors require knowledge of
the short- and long-term effects of abuse and the range of therapeutic responses and
interventions that may be appropriate in different circumstances. Therapeutic need
and selection of methods for intervention should be informed by theory and research
whenever possible. It is also useful for therapists to have some understanding of what is
known about sexually abusive behaviour, especially the ‘grooming’ process — the strate-
gies used by perpetrators of abuse to intimidate, disempower and silence their victims
(Finkelhor, 1984). Therapists also need to keep up to date with developments in ‘child
sexual exploitation’ and also what is known about needs of children who harm other
children.
In situations where there is uncertainty about how best to intervene, the following
suggestions may be helpful. Where trauma is clearly apparent and ‘symptom’ reduc-
tion a priority, as in cases of post-traumatic stress, a cognitive-behavioural approach
may be indicated (Deblinger et al., 2006). Where isolation and self-esteem are primary
concerns, therapy within a group setting might be more effective than individual couns
elling (Doyle, 2012). Where trust is an issue and the client ambivalent about being
referred, it may be that progress will best be achieved through a slow, careful process
such as person-centred counselling or play therapy (Doyle, 2012). Therapeutic objec-
tives are numerous and multi-faceted ranging from working through feelings (such as
anger, loss, guilt and shame) to directly focussing on reducing behaviours that may be
harmful. Improving self-image and self-esteem may also be valid goals as may repair-
ing and strengthening relationships with significant others.
In reality, it is often left to each therapist to assess and provide what they believe
to be appropriate which, inevitably, is influenced heavily by each therapist’s training
and theoretical orientation. What a child is offered will depend to a large extent on
where they live, to whom they are referred and how knowledgeable and experienced
the therapist is. Methods of intervention are likely to be influenced as much by cost and
availability as suitability and efficacy and it is not uncommon these days for therapists
to be allowed only a small number of sessions in which to work with each child,
The case study below is intended to give a flavour of the various ways in which chil-
dren who have been abused might be assisted.
 Sexual, Physical and Emotional Abuse 359

Case Study Tina

When Tina was born, her mother experienced post-natal depression and was unable to bond with
her. For the first eight months of her life Tina was cared for by her father, and her emotional needs in
particular were neglected. She received little warmth and affection and spent many hours strapped
in a buggy with a soother in her mouth. Tina’s parents’ relationship involved frequent episodes of
domestic violence, both parents being physically and verbally abusive to one another. On more than
one occasion, Tina was caught in the crossfire, once sustaining a blow to the head. This was not
reported and her injury was never noticed by others. When Tina was two, her parents separated and
her father went to live with another woman who was expecting his child. Soon after the baby was
born, he left the area and never saw Tina again. Tina’s mother became extremely bitter towards Tina’s
father and these feelings persisted throughout Tina's pre-school years. Tina bore a close resemblance
to her father, which grew more noticeable with each passing year. Tina’s mother often shouted at and
insulted her, telling her she was ‘an ugly pig, just like him!’
By the age of 11, Tina had two younger half-brothers, aged five and seven, whose father had left
shortly after the youngest was born and had no contact with them. Tina spent most evenings and
weekends looking after the boys and doing domestic chores. Her mother worked in the offices of a
local taxi company and was often out during the evenings, leaving Tina to feed and supervise the
boys and put them to bed. Tina loved her brothers and went to great lengths to make sure the fam-
ily’s domestic situation did not come to the attention of school or the local authority. Social workers
had followed up anonymous referrals on two occasions but Tina and her mother had presented a
united front and convinced them these referrals were malicious and without grounds. ‘ina stayed
‘below the radar’at school, maintaining acceptable levels of attendance and avoiding attention. Tina
had no friends to speak of and the only affection and happiness in her life was through the boys. Tina
was afraid that she and her brothers would be taken ‘into care’ if details of their family life were ever
to be discovered.
When Tina was 13, her mother began a relationship with Dave, a man she had met at work. Dave
moved in with the family and life changed dramatically. Tina's mother was happier than Tina had ever
known and the shouting and criticism that had hitherto been a constant feature of her life virtually
stopped. Dave was kind to Tina and used his tips to buy her presents, which hejokingly told her not
to tell the others about. No-one had ever made Tina feel special before and she came to like and
trust Dave a great deal. Tina did not know that these were the beginnings of an elaborate grooming
process that would eventually lead to sexual abuse.
At the age of 15, Tina was admitted to hospital having taken an overdose of painkillers with cider.
Hospital records showed that she had been admitted three months earlier with a broken arm which
was said to have been caused falling downstairs. During a series of interviews with a psychiatrist,
Tina disclosed sexual abuse and later, in the presence of a social worker, made a formal statement to
the police alleging rape by Dave over an 18-month period. Professionals learned that she had tried
(Continued)
ue
 360 The Handbook of Counselling Children & Young People

(See

unsuccessfully to draw attention to the abuse a few months earlier by throwing herself down the
stairs at home. Medical examination revealed numerous scars to Tina’s arms and legs that had been
self-imposed. Dave had used many strategies to silence Tina, convincing her that she was to blame
and that no-one would believe her if she told. On discharging her, the psychiatrist concluded that
Tina’s was not a serious attempt to take her own life but rather a classic ‘cry for help: The report stated
that Tina had not expressed any emotions at all during her time in hospital and seemed to have ‘no
sense of self-worth whatsoever’.

Therapeutic Responses
The aftermath of the disclosure and ensuing child protection investigation was traumatic for Tina.
Tina's mother did not believe her and refused to have any further contact with her. Tina was placed
with foster-carers who lived many miles away. She was able to speak to her brothers by telephone
but opportunities for direct contact were few. Initially, Dave denied the allegations. However, faced
with forensic evidence, he admitted the abuse but claimed Tina had ‘led him on’ Tina’s mother sup-
ported Dave and agreed to cooperate with an in-depth, formal assessment to identify risks to the
boys. Dave was charged and bailed awaiting trial. He was not allowed to live with the family or to
make contact with Tina. He was subsequently sentenced to a term of imprisonment, something Tina
felt incredibly guilty about.
A multi-agency plan was put in place to address Tina's needs. Included in the plan was a recom-
mendation she be offered ‘post-abuse counselling: Tina found talking about the abuse very difficult
and was reluctant to see a therapist but not assertive enough to refuse. During the first year following
disclosure, two attempts at establishing therapeutic relationships failed, with counsellors concluding
that it was the wrong time. Tina’s care team prioritised her home and school life, eventually finding
a foster carer, Ann, who was willing and able to commit to Tina long-term. This enabled Tina to start
afresh in a new school and to experience nurture and care for the first time in her life. She lost weight,
joined the school running club and began to form friendships.
Ann understood that Tina had difficulties expressing her emotions and was sensitive enough not
to push this. She was respectful of Tina’s privacy and personal space and noticed over time that Tina
became more relaxed in her presence and more able to hold short conversations. Some members
of the care team remained concerned that Tina had never talked about what Dave had done to her
and felt that some of the distorted thinking and self-blame that had been evident in her sessions
with the psychiatrist needed to be addressed. Encouraged by Ann, Tina agreed to give counselling
another go.
Tina’s counsellor, Louise, was trained in person-centred counselling and play therapy. She
was Creative in her methods and her counselling room was bright, cheery and had artwork and
poetry on display. Louise understood the importance of establishing clear boundaries and took
a lot of time explaining to Tina what counselling involved, how she worked and what to expect.
 Sexual, Physical and Emotional Abuse 361

She involved Tina in negotiating a working agreement and made use of every opportunity that
arose to empower Tina, knowing that feelings of powerlessness are common in children who
have been abused. Although Louise did not know the details ofTina’s early life, she was experi-
enced enough to know that Tina's poor self-esteem and difficulties expressing emotion might
pre-date the sexual abuse and that she should not allow assumptions to creep into her work.
Although she was curious to know more about Tina's early years and her relationship with her
mother, Louise trod carefully, letting Tina lead the way. Louise had to be strong and assertive
over this issue. Some members ofthe care team did not think she could work properly with Tina
without understanding what was now on record as a ‘chronic history of physical, sexual and
emotional abuse’ Others were concerned that the work lacked focus and that clearer objectives
needed to be set in order to justify the funding. Louise trusted her instincts, refusing to allow
others to set the therapeutic agenda. She relied on supervision to help her remain focused on
her therapeutic process with Tina.
Over a series of 12 sessions taking place in two blocks of six with a review mid-way, Louise and
Tina worked together, supported by Ann, who encouraged attendance but never asked to be told
the details. Louise had warned Ann that there might be times when Tina would seem upset by the
sessions or even that the sessions might seem to be making her worse. Louise prepared Ann care-
fully in order to reduce the risk of her undermining the process. She also did this with members of
the care team, making clear that with the exception of information suggesting ongoing risk of harm,
no detailed feedback would be provided on the content of the sessions. She explained that affording
confidentiality gave the counselling a better chance of success.
Louise’s person-centred approach enabled her to establish a working relationship with Tina. She
understood that direct conversation was hard for Tina so made use of various mediums to facilitate
communication. A significant breakthrough occurred when Tina was making a pebble sculpt and
Louise offered her a box of buttons to supplement the stones. Tina was drawn to a particular button
which she held and stared at. Tears began to pour down her face - the first show of emotion Louise
had witnessed. Remaining calm and staying with the process, Louise used congruence to acknowl-
edge what was happening and Tina began to talk in detail about her brothers and her sorrow at
being separated from them. She also revealed snippets of the neglect, physical and emotional abuse
that had characterised her early life.
In subsequent sessions, Tina drew pictures of herself and her brothers, representing herself as
fat and ugly. She was able to tell Louise that her mother had referred to her as ‘the Pig’ and that
she had been teased at school for being overweight and smelly. At times, Louise had to work very
hard to contain her own feelings and remain focused. She longed for Tina to realise that she was
in fact a very beautiful young woman and was staggered that Tina believed herself to be ugly and
unlovable. She was a mother herself and could not imagine how Tina’s mother could treat her own
daughter in this way. She felt utter fury towards this woman who she would never meet. At times,

(Continued)
Z
 362 The Handbook of Counselling Children & Young People

a oy
(Continued)

she fought strong urges to express this anger. Louise knew that Tina might have deep-rooted and
ambivalent feelings towards her mother and that an ill-judged comment could jeopardise their
working relationship. There were times during her work with Tina that Louise had a strong urge to
reach out and physically comfort her.
At the start of one session, Tina asked Louise if they could play a word game she had on her mobile
phone. This was slightly unconventional but Louise decided to agree and see where it went. Louise
quickly realised that Tina had introduced this game so that she could talk about difficult things with-
out needing to make eye contact. At the end of the session, she saved the game on the screen and
brought it back unchanged to the next session. On the third occasion, Tina typed the word ‘slut;
almost inviting Louise to comment. Louise felt that a door had been opened and, taking care not
to make any assumptions or judgements, she gently enabled Tina to begin talking about the sexual
abuse and the impact it had had on her.
What emerged was the story of a needy, vulnerable little girl who had been desperate for affec-
tion and easy to manipulate. Dave had told Tina that she was the ‘daughter he never had’ and that
he was going to protect and care for her the way a father should. When he had begun to sexually
abuse her, he had told Tina that most fathers did this and that it was his ‘job to introduce her gently
to being a woman’ Tina had no friends at school and no-one to check this out with. Her mother had
been less hostile towards her since Dave's arrival and Tina was terrified that talking to her would
spoil everything. By the time touching turned into rape, Tina had been made to feel that she had
cooperated with the abuse and had encouraged it. Dave always gave her sweets and money and
made her feel that these were in payment for sex. She had thrown herself downstairs hoping that
the abuse would be discovered but this did not work. Tina’s overdose had been an expression of
her powerlessness and self-loathing, as had been several months of self-mutilation. Louise was
aware that many children who have been sexually abused feel great shame about their bodies
having responded to the abuse and to it being physically pleasurable. She took great care not to
say anything about how the abuse must have felt or to make any judgements about how Tina felt
about Dave.
Working with Tina's new-found openness, Louise was able to help her think about what had hap-
pened to her and begin reducing the level of self-blame that had been instilled. Louise also realised
that Tina might now be able to make use of a therapeutic group where more direct approaches to
challenging distorted thinking could be used.

Group Work
Tina agreed to attend a therapeutic group for girls who had been sexually abused and made fur-
ther progress as a result. Group leaders did not share any of the content of the sessions outside
the group, although the weekly agenda and activities they used were passed on to other profes-
[sonaland carers. Within this group, Tina was enabled to participate in activities that focused ay)
 Sexual, Physical and Emotional Abuse 363

a
body-image and self-esteem. She was shown DVDs made by other groups of girls who had ‘sur-
vived’ sexual abuse and, in a variety of ways, was helped to realise that she was not alone in this
experience and that sexual abuse is never the child’s fault. She was enabled to share some of the
ambivalent feelings she had towards her abuser and non-protecting parent and to hear that this
was not uncommon. Tina had hoped that if she was examined, doctors would discover she was
being abused; this was because she believed that signs of sexual abuse were noticeable. Many
children think they are forever damaged by abuse and have heard many myths about never being
able to have children, going on to become abusers and so on. Attending the group enabled some
of the myths that reinforced Tina’s low self-esteem to be dispelled. It also allowed taboo subjects
and some of the most embarrassing, humiliating aspects of abuse to be explored in a safe and
sensitive way.
Individual and group counselling were valuable stages in Tina’s ‘recovery’ process. However,
the effects of her early abuse and neglect were not so readily addressed through therapy. Tina
had two very good experiences of therapeutic relationships and, crucially, was provided with
appropriate care and a place to live where she felt loved and wanted. Practical steps were taken
to try and facilitate more contact with her siblings, which proved to be a very complicated
process.

Tina’s story is fictitious but borrows aspects from the lives of real children and young
people. Although theory, research and policy differentiate child abuse into the catego-
ries of physical, emotional, sexual and neglect, the reality is that there is much overlap
between them, as Tina’s story demonstrates.
Despite these challenges, this is an extremely worthwhile and rewarding area to
work in, having potential to make a huge difference to a child’s well-being in both the
short- and long-term. The theory and research in this area can be fascinating to study
and there is great potential for creativity in practice, making it well worth the effort of
developing the knowledge and skills necessary to be effective.
Working with children who have been abused is extremely challenging and is not for
everyone. The emotional impact on the counsellor of hearing first-hand and in-depth
the stories of children who have been abused cannot be underestimated. This work
carries with it a significant risk of compassion fatigue (Figley, 2002) and it is essential
the counsellor avails him- or herself of high quality supervision from a supervisor who
is experienced in this area. It is rarely obvious at the outset what method of intervention
is most likely to be successful, and sometimes it can be a struggle to establish the trust
necessary to engage the client. At times it can be incredibly frustrating to witness the
damage done to children both by abusers and the system around them, and to feel
powerless to change this. Sometimes, through parallel process, therapists may even
begin to experience some of the same feelings as their clients and it is not uncommon
 364 The Handbook of Counselling Children & Young People

for them to take to supervision feelings such as anger, frustration, sorrow, fear, guilt and
even shame (see Chapter 13).

Summary

e There is evidence to suggest that child abuse can have a lasting impact and that counselling
and therapy may improve outcomes for children
e The research base is developing rapidly but, as yet, there is insufficient evidence to evaluate
the effectiveness of all forms of therapeutic intervention
e Counsellors have a range of options open to them and should be guided by some important
principles including certain pre-requisites to offering counselling/therapy, avoidance of label-
ling, importance of listening to children and managing the legal process in the best interests
of the child
e This area of work can be very demanding and counsellors should remain alert to issues of
parallel process, transference and counter-transference and compassion fatigue, ensur-
ing they have access to an appropriately trained and experienced supervisor

Reflective Questions

1 Do you think any of Tina’s experiences are likely to affect her

permanently?

There is some evidence to suggest that abuse and neglect in infancy may damage the
developing brain (Gerhardt, 2004). However, more research is needed in this area. In
other respects, it is important to remain positive and have an optimistic outlook about
the capacity of humans to survive trauma and abuse. Research in this area is inherently
flawed in that we can never know how many people were abused in childhood, live full
and happy lives and choose never to speak of their experiences. These people are absent
from our statistics and what we have therefore may be a skewed sample of children and
adults who we know about because of their struggles. Therapy is the perfect place for
distorted thinking to be addressed and for clients to discover what coping strategies
work for them. The survivor stories in Strong at the Broken Places speak for themselves
(Sanford, 1991).
 Sexual, Physical and Emotional Abuse 365

2 How might intervention need to be different if there was only

funding for six sessions?

Where intervention is limited to six sessions, therapists have to think strategically

about their chosen method. Goal-based interventions may be more realistic than the
approach used in the case study. During the contracting stage, clients choose which
issues they wish to work on and the counsellor helps to ensure the target is realistic. The
principle of ‘non-maleficence’ should be applied; sometimes it is more harmful to cre-
ate expectations that cannot be met and therapists must avoid this wherever possible.

3 Are there any circumstances in which therapeutic intervention

should be withheld?

e Where other needs are more pressing and counselling may undermine the meeting of
these, e.g. settling into a new home/school, undertaking examinations.
e Where there is a strong risk that therapy may undermine the legal process and the client's
greatest priority is the conviction of the perpetrator.
e Where the client does not want therapy and the referral is driven by others (this depends
on the age ofthe child and their ability to make an informed choice).

4 What is the ideal physical environment in which to do

therapeutic work with children and young people who have been
abused?

In an ideal world, therapy will take place in a purpose-built environment, equipped with
resources to enable the full range of interventions the therapist is skilled to offer. In reality,
such places are not always available. Each therapist needs to consider their working envi-
ronment and how this matches the needs of their clients. Children who have been abused
may have a great need to feel safe and to be assured of privacy and guaranteed of no inter-
ruptions. They may be more sensitive than others to the stigma attached to counselling and
believe that everyone knows what has happened to them. On the other hand, some children
who have been abused may feel uncomfortable or even threatened by environments that
are too intimate. Therapists should be aware that some places have certain associations and
where possible, seek the client’s view about where and when sessions should be held. The
counsellor feeling at home should always come second to finding the right environment for
the client. This should be thought about as part of the referral and planning process.
366 The Handbook of Counselling Children & Young People

5 What level of confidentiality should be offered within the

counselling relationship?

The same principles of confidentiality apply to this client group as any other (see
Chapters 17 and 18). Information has to be shared where the therapist is made aware
that a child is at risk of significant harm. It is not unusual for children to disclose
new information about abuse during therapy. The counsellor needs to be prepared
for this and build into the contract what action would be taken in this event. It is
unusual for children (especially older children) to ‘accidentally’ disclose, especially
if it has been made clear to them that such information would have to be passed on.
In these situations, the counsellor should empower the client by sharing information
about what will happen next and allowing them choices wherever this is possible.

* ¢
Learning Activities

1. Make contact with your Local Safeguarding Children Board (LSCB) and find out what rel-
evant training is available to you. Attending events such as ‘Child Protection Awareness
Workshops’
will give you an opportunity to think about child abuse within a multi-disci-
plinary forum and help you to understand how counselling fits within the wider context
of safeguarding children.
i Reflect on your theoretical orientation and preferred method of intervention and con-
sider the extent to which it lends itself to working with children or young people who
have been abused. Ask your supervisor to read this chapter, then discuss it together.
ot If you have never worked with a child who has been abused before, consider how prepared
you would be if a child disclosed abuse during a session with you. Would you know how best
to respond? Would you know how to respond therapeutically whilst following your agency’s
ee
=
RUS safeguarding procedure? (|f not, the workshops outlined in point 1 above will help.)
SSE eS a re =a = < = ma So ee ee ee et be ees 0

Further Reading

Allnock, D. and Hynes, P. (2012) Therapeutic Services for Sexually Abused Children and Young People:
Scoping the Evidence Base. London: NSPCC
Daniels, D. and Jenkins, P (2010) Therapy with Children: Children’s Rights, Confidentiality and the
Law, 2nd edn. London: SAGE.
 Sexual, Physical and Emotional Abuse 367

Deblinger, E., Mannarino, A.P., Cohen, J.A. and Steer, R.A. (2006) ‘Follow-up study of a multisite,
randomised control trial for children with sexual abuse-related PTSD: Examining predictors
of treatment response’, Journal of the American Academy of Child and Adolescent Psychiatry, 45:
1474-1484.
Doyle, C (2012) Working with Abused Children. 4th edn. Basingstoke: Palgrave Macmillan.
Geldard, K., Geldard, D. and Yin Foo, R. (2013) Counselling Children:APractical Introduction. 4th edn.
London: SAGE.
Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby's Brain. Hove: Brunner—
Routledge.
Mudaly, N. and Goddard, C. (2009) The ethics of involving children who have been abused in child
abuse research’, International Journal of Children’s Rights, 17: 261-281.

Online Resources

Counselling MindEd: http://counsellingminded.com.

 Eating Disorders
Erica Allan, Elizabeth K. Hughes and
Daniel Le Grange

This chapter includes:

RIES PITTI LB LEDER OEE SLEDS ESOL ESTEEEBERLE BEB ESSEC IIS LIESELES DELLE IEEE BELLI BITES III SEP LEED EN ESB ILE LLAISI

e Information about eating disorders and their presentation in children and adolescents
e Speculations about the aetiology of these disorders
e Adescription of the most prominent psychosocial treatments for these disorders

The authors of this chapter have experience in the assessment and treatment of young
people with eating disorders. The senior author (DLG) has been working as a clinical
researcher in the field of adolescent eating disorders for the past 25 years. He received
his training at the Maudsley Hospital in London in the 1980s, and has since then been
at the forefront of developing and evaluating psychosocial treatments for adolescents
with eating disorders. The first (EA) and second (EH) authors are close research col-
laborators and have been working with DLG for more than three years. Together, they
have been primarily involved in managing a clinical trial for adolescents who present
at a tertiary educational hospital in a metropolitan area. In this role, EA and EH have
been working with a large multi-disciplinary team of clinicians who run a specialist
inpatient and outpatient treatment programme for adolescents with eating disorders.
Through this endeavour, all three authors are at the forefront of the clinical presentation
of children and adolescents with eating disorders, and evaluating the best evidence-
based practice for these complex disorders.
 Eating Disorders 369

Eating Disorders: Definitions

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American

Psychiatric Association, 2013) describes the eating disorders as follow; anorexia
nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive
food intake disorder, and other specified feeding or eating disorder. Eating disorders
usually onset in early to mid-adolescence (Swanson et al., 2011), and are complex
psychiatric disorders associated with significant short- and long-term physiologi-
cal and psychological morbidity and high rates of mortality (Crow et al., 2010).
Rates of morbidity and mortality are among the highest of any psychiatric disorder
(Herpertz-Dahlmann, 2009), with the physical development of children and ado-
lescents being affected by medical complications such as bradycardia (slow heart
rate) (Misra et al., 2004), osteopenia or osteoporosis (low bone density) (Allan et al.,
2010), biochemical instability, hypothermia, hypoglycaemia (low blood glucose
level) (Gaudiani et al., 2012), fatigue (Bulik et al., 2005) and amenorrhoea (absence
of menstrual periods) (Herpertz-Dahlmann, 2009). High rates of psychiatric
comorbidity such as depression, substance abuse (Rosling et al., 2011), suicidality
and suicide attempts (Swanson et al., 2011), anxiety, self-consciousness (Bulik et al.,
2005), social isolation (Beumont and Touyz, 2003), and obsessive compulsive
disorder (Herpertz-Dahlmann, 2009), are often experienced and can have profound
impact on psychological development of children and adolescents with eating dis-
orders (Bulik et al., 2005).

Anorexia Nervosa (AN)

Anorexia nervosa (AN) is characterised by a) inability to maintain an appropriate body

weight for age and height; b) an intense fear of weight gain or becoming fat, or engaging
in behaviours that prevent weight gain; and c) a distorted sense of body weight or size,
or denial of the seriousness of low weight (American Psychiatric Association, 2013). It
is important to note that in adolescents, there may be a failure to gain weight during
a period of growth rather than weight loss (American Psychiatric Association, 2013).
AN is divided into two subtypes; restricting subtype, where binge eating or purging
is not the main feature, and binge-eating/purging subtype, where binge eating and/or
purging is a main feature (American Psychiatric Association, 2013). AN often emerges
in adolescence (Lock and Le Grange, 2005a; Golden, et al., 2008), with a median age of
onset of 12.3 years (Swanson et al., 2011), and an average illness length of seven years
(Beumont and Touyz, 2003). The lifetime prevalence of anorexia nervosa in adoles-
cents has been estimated at 0.3 per cent (Swanson et al., 2011).
370 The Handbook of Counselling Children & Young People

Bulimia Nervosa (BN)

Bulimia nervosa (BN) is characterised by frequent episodes of binge eating, followed

by unhealthy compensatory behaviours aimed at preventing weight gain that occur
on average once a week for three months (American Psychiatric Association, 2013)
An episode of binge eating is defined as consuming an objectively large amount of
food in comparison to others in a similar period of time and circumstances, and
a sense of loss or lack of control, i.e., either not being able to stop or control how
much is being eaten (American Psychiatric Association, 2013). Inappropriate com-
pensatory behaviours most often include self-induced vomiting, laxative and/or
diuretic misuse, excessive exercise, enemas, or fasting. Further, and like AN, BN
involves an undue emphasis of body weight and shape on self-evaluation (American
Psychiatric Association, 2013). Individuals with BN generally do not present as
being underweight, though some patients may be at the lower range of normal
(Herpertz-Dahlmann, 2009). The median age of onset for BN is 12.4 years and the
lifetime prevalence of this disorder has been estimated at 0.9 per cent in adolescents
(Swanson et al., 2011).

Binge-Eating Disorder (BED)

Binge-eating disorder (BED) is characterised by frequent episodes of binge eating

that occur once a week for three months, and is associated with a feeling of distress
(American Psychiatric Association, 2013). Further, these binge episodes are associ-
ated with three or more of the following: feelings of disgust or guilt after the episode,
consuming food at a more rapid pace than usual, consuming a large amount of food
though not physically hungry, eating until feeling uncomfortably full, or feelings of
embarrassment over the amounts of food consumed leading to eating alone. Unlike
BN, binge episodes are not associated with compensatory behaviours (American
Psychiatric Association, 2013).

Avoidant/Restrictive Food Intake Disorder

Avoidant/restrictive food intake disorder is characterised by a disturbance in eating

that results in reduced nutritional or energy intake and is associated with an impact on
functioning, reliance on nutritional supplements, nutritional deficits, or loss of weight
(American Psychiatric Association, 2013).
 Eating Disorders 371

Other Specified Feeding or Eating Disorder

Other specified feeding or eating disorder is a heterogeneous category of eating dis-

orders, used as a diagnosis when the full DSM-5 criteria are not met for anorexia
nervosa, bulimia nervosa, or binge-eating disorder. Those falling within this category
may present with aspects of AN, BN, or BED without meeting full thresholds for those
disorders (Beumont and Touyz, 2003; Turner and Bryant-Waugh, 2005; Eddy et al.,
2008). For example, a young person might meet all of the diagnostic criteria required
for a diagnosis of AN, but may not have lost sufficient weight to put them below their
expected body weight.
In a population-based survey within the United States, the prevalence of subthreshold AN
in adolescents, defined as a lowest body weight of less than 90 per cent of expected body
weight and an intense fear of gaining weight, was estimated at 1.6 per cent (Swanson et
al., 2011). Using data from the same survey, Le Grange et al. (2012) found the lifetime
prevalence rate of DSM-IV-TR Eating Disorder Not Otherwise Specified (EDNOS)
in adolescents to be 4.78 per cent, which included binge eating disorder (BED), sub-
threshold AN (SAN), and sub-threshold BED (SBED). These authors also reported that
for those with a lifetime diagnosis of an eating disorder, EDNOS accounted for 80.97
per cent of all eating disorder diagnoses among adolescents. Although full diagnostic
criteria for a specific AN or BN diagnosis may not be met, it is important not to view
sub-syndromal eating disorders as any less severe than either a diagnosis of AN or BN.
Several studies (e.g. Eddy et al., 2008; Peebles et al., 2010; Swanson et al., 2011) have
now demonstrated that patients who do not meet full diagnostic criteria for AN or BN
are both medically and psychiatrically as unwell as patients meeting full criteria for
AN and BN. Moreover, mood disorders, anxiety disorders and suicide plans have been
found to be more common among adolescents with a sub-threshold diagnosis than
those with AN, while also reporting similar frequency of substance use and behav-
ioural disorders (Le Grange et al., 2012).
It is important to recognise that it is sometimes difficult to arrive at a DSM-IV diag-
nosis of an eating disorder in many children or young adolescents. For instance, young
patients may not have the cognitive maturity to express their concerns for weight gain,
or they may present with a loss of appetite rather than intentional weight loss, or are
prepubertal and therefore rendering the loss of menses criterion obsolete. It is for these
reasons that there may be a delay in the identification and diagnosis of eating disor-
ders in younger children. A recent opinion piece (Bravender et al., 2010), prior to the
publication of DSM-5, argued for the re-evaluation of the DSM criteria for eating dis-
orders and how these may have to be adjusted for younger patients. Consequently, the
diagnostic criteria for AN, BN and EDNOS were revised in the DSM-5 manual. The
changes to the AN criteria excluded amenorrhoea as a criterion for diagnosis. Criteria
372 The Handbook of Counselling Children & Young People

for BN were also amended, reducing the frequency of binge-eating episodes and com-
pensatory behaviours from twice per week to once per week for the previous three
months. In addition, BED was recognised as a stand-alone eating disorder rather than
bracketed within DSM-IV EDNOS (c.f. www.dsm5.org).

Historical and Theoretical Perspectives

The diagnosis and treatment of eating disorders have changed dramatically since they
were first identified and described. Although there may be earlier accounts of AN, it
was not until the latter part of the 19th century that Charles Lasegue in France and
William Gull in England provided the first accounts of this disorder (Habermas, 1989;
Striegel-Moore and Bulik, 2007). BN was initially described by Gerald Russell at the
Maudsley Hospital in London, but not until 1979 and only included in the third edi-
tion of the DSM in 1987. Early therapeutic models promoted the isolation of children
and adolescents by removing them from the care of parents (Silverman, 1997). These
early therapeutic models were focused on the idea that family interactions contribute
to the development of eating disorders. It is now recognised that the family, especially
parents, play an important positive role in the treatment of young people with eating
disorders (Lock and Le Grange, 2005a; Le Grange et al., 2010).
Despite a growing body of research, the causes of eating disorders remain largely
unknown. However, it is thought that genetic factors, personality traits and thinking
styles, physiological changes associated with starvation, and puberty all may contribute
to the development of these disorders (Herpertz-Dahlmann et al., 2011). One of the
most consistent findings is that the risk of developing AN is increased in those with
immediate relatives with AN (Bulik et al., 2005, 2006, 2010). Socio-cultural influences
are also often cited as contributing to the development of AN as it has been found to be
more common in industrialised countries, and the prevalence of eating disorders has
been observed to increase with the introduction of media endorsing thin ideal body
standards (Becker et al., 2002). Overall, it is thought that a combination of biological
and cultural factors contributes to the development of eating disorders (Striegel-Moore
and Bulik, 2007).
There is a tendency for eating disorders to be viewed as mostly occurring among
females, with the majority of research, treatment models and resources, particularly
for AN, focusing on females (Strother et al., 2012; Wooldridge and Lytle, 2012). Few
studies have reported the incidence of AN in males (Hoek and van Hoeken, 2003), but
the ratio of females developing AN in comparison to males is typically cited as 10:1
(Currin et al., 2005). Previous research has demonstrated that among males with eating
disorders, AN is a more common diagnosis than BN (Norris et al., 2012).
 Eating Disorders 373

Key Models of Engagement and Intervention

Few psychotherapeutic interventions have been systematically tested for the paediatric
eating disorders population. Fewer still have proven to be efficacious (Lock and Le Grange,
2005a). In this section of the chapter, we will briefly review four treatment modalities that
have received relatively robust research support for this clinical population.

Family-Based Treatment (FBT)

Family-based treatment (FBT) was developed at the Maudsley Hospital, London, as an

outpatient therapy for AN in adolescents. Within this model, adolescents with AN are
viewed as being ‘overtaken’ by their disorder and are therefore unable to make healthy
decisions about their nutritional intake. Parents are guided by a therapist in restoring
their child’s weight to a healthy level. Treatment occurs over three phases, with the first
phase concentrating primarily on weight gain, and returning the adolescent to their
healthy weight. During this phase, parents are given the responsibility of making all
decisions regarding food and eating. As weight steadily increases and resistance to eat-
ing sufficient amounts of healthy food required for weight gain is reduced, the family is
guided into phase two. During this phase, parents are encouraged to gradually reduce
their control over eating decisions and return these decisions to the young person in an
age appropriate way. Phase three of FBT concentrates on adolescent developmental issues
and refocusing family relationships to relevant adolescent developmental concerns,
especially as the illness no longer occupies centre stage (Lock and Le Grange, 2012).
FBT for AN is typically conducted in ~20 sessions over a period of six to 12 months.
The first phase would last three to five months and consists of about 50 per cent of the
treatment sessions (1-10). Phase two lasts two to three months (sessions 11-16), while
phase three concludes the treatment over a two-month period of sessions 17-20 usu-
ally conducted at three-weekly intervals.
There have been several studies demonstrating the effectiveness of FBT as a treat-
ment for adolescents with AN. Overall, these studies have demonstrated that 50-75 per
cent of adolescents who receive FBT respond well and achieve weight restoration, and
60-90 per cent are fully recovered at four to five year follow-up (for a summary, see Le
Grange and Eisler, 2009).
Family-based treatment for BN (FBT-BN) has also been developed for adolescents
with bulimia nervosa. It is a three phase treatment that does not focus on exploring the
cause of the disorder, instead focusing on managing and treating the symptoms. It is
recognised that the disorder has a negative effect on the adolescent's development and
374 The Handbook of Counselling Children & Young People

disempowers parents. The treatment emphasises a collaborative approach between

the parents and adolescent and they are encouraged to work together to combat the
symptoms of the illness. As in FBT-AN, the therapist aims to absolve the parents of
any guilt associated with the perception of having caused the illness and encourages
the parents to view the illness as external to their child. Parents are also encouraged to
be united in their efforts to help their child recover and the therapist aims to empower
them through encouraging and guiding them in making their own decisions in help-
ing resolve the bulimia symptoms (Le Grange and Lock, 2007). FBT-BN differs from
the AN version as it does not focus on weight gain, focusing instead on reducing the
episodes of bingeing and purging as well as promoting regular eating (Le Grange and
Lock, 2007).
Although research has primarily focused on FBT for AN adolescents, with few
exceptions, the principles of FBT are similar when treating children with BN. The
main difference is in phase one of FBT-BN where the therapist will provide the ado-
lescent with more of an opportunity to participate in the decision-making around
healthy eating. This principle is primarily supported by the premise that BN in
adolescents is fundamentally experienced as more ego-dystonic, ie. symptoms are
experienced as unpleasant and unwanted. AN, on the other hand, is mostly expe-
rienced as ego-syntonic, i.e., symptoms are viewed with pride and any attempts at
intervention are fiercely rebuffed. Therefore, an adolescent with BN, at least in part,
is motivated not to engage in binge eating and purging behaviours. Starvation is
almost always experienced as desirable and to be ‘protected’ by the sufferer. For the
most, though, FBT-BN follows the same therapeutic steps as FBT-AN (Le Grange
and Lock, 2007).

Cognitive-Behavioural Therapy (CBT)

Within the CBT model, extreme weight control measures are seen as being driven by
shape and weight concerns (Wilson, 2005). As a treatment for BN, the aim is to reduce
the emphasis that is placed upon shape and weight while also developing mechanisms
to deal with situations that may lead to bingeing and purging (Wilson, 2005). The aim
of CBT for AN is to improve health by addressing the irrational thoughts that per-
petuate the illness and altering the way starvation and exercise are viewed (Wade and
Watson, 2012). Other factors that contribute to the eating disorder, such as poor self-
esteem and perfectionism, may also be attended to during CBT sessions (Wade and
Watson, 2012). CBT has received little attention in adolescent eating disorders with
only one published RCT for adolescent AN (Gowers et al., 2007) and one for adolescent
BN (Schmidt et al., 2007). In neither of these studies did CBT prove to be more effica-
cious than the comparison treatments.
 Eating Disorders 375

Other Therapeutic Interventions

Individual ego-oriented therapy, also referred to more recently as adolescent-focused

therapy (AFT) (Fitzpatrick et al., 2010), is an individual therapy used to treat ado-
lescents with AN. The primary aim of AFT is to address issues regarding identity, as
well as social and emotional maturation. A recent large RCT of FBT versus AFT for
adolescent AN, demonstrated similar rates of full remission at the end-of-treatment.
However, FBT was superior to AFT at six- and 12-month follow-up, and those in FBT
generally showing an earlier response to treatment and less likely to relapse at follow-
up once fully remitted at end-of-treatment (Lock et al., 2010).
Individual supportive psychotherapy (SPT) is a treatment for BN adapted for use
in adolescents from an adult version. It involves three phases, with the first phase
focused on building therapeutic rapport and gaining information regarding the patient’s
history of her/his eating disorder, and helps the adolescent identify issues that might
be related to the development of the eating disorder. Phase two focuses on exploring
emotional issues and concerns, while phase three addresses preparation for treatment
termination and relapse prevention, i.e. identifying potential issues that may arise in
the future. In a comparison of SPT and FBT-BN, it was found that those treated with
FBT-BN were able to gain symptomatic relief more quickly than those in SPT. FBT-BN
was also more efficacious than SPT at end-of-treatment and at six-month follow-up
(Le Grange et al., 2007).

Case Study Belinda

Belinda is a 15-year-old female who presented to the eating disorders outpatient clinic with her par-
ents. She was referred by her GP after her parents became increasingly concerned over her loss of
weight, restrictive eating patterns and social isolation.
Belinda described a long-standing history of body dissatisfaction and concerns about her
shape and weight. Although she had felt this way for several years, it was in the previous six
months that Belinda had decided to ‘do something about it’? Consequently, Belinda increased
her exercise and reduced her portion sizes at meal times. Although Belinda originally aimed to
lose a small amount of weight, she soon became driven to lose more weight and admitted that
she ‘could not imagine being happy at any weight’. Belinda described a gradual decrease in the
portion sizes of her meals and variety of foods eaten, having become a vegetarian within the
past six months. Although Belinda was actively avoiding foods she had previously enjoyed, such

(Continued)
 376 The Handbook of Counselling Children & Young People

((conan

as chocolate and take-aways, she described this as only occurring because she didn’t want to
eat unhealthy foods.
Belinda’s parents, Anne and Jacob, became aware of a change in their daughter's habits in the six
months prior to their presentation to the clinic. Anne had become concerned when Belinda decided
to become a vegetarian but thought it might be a passing phase. However, Belinda began to fur-
ther restrict both the variety and quantity of foods. When offered foods and meals that Belinda had
previously enjoyed, she claimed that she no longer liked these foods or that they made her feel
unwell. Further, Belinda spent many hours looking at recipe books and preparing meals for the rest of
the family, unwilling to eat what Anne had prepared. Anne and Jacob became especially concerned
when they observed Belinda becoming very anxious at the suggestion of having dinner at a restau-
rant that ‘did not have healthy options’ Anne has also observed Belinda weighing herself on a daily
basis and appearing to pinch her stomach, arms and thighs.
Upon examination, Belinda’s extremities were cold and she described herself as feeling cold con-
stantly. Her weight put her below 85 per cent of her expected body weight for her age and height
and she expressed concern over not having menstruated in the previous four months. She denied
purging or laxative misuse but became tearful when describing the guilt experienced after feeling
that she had eaten too much. Although she described feeling a sense of loss of control, the amount
that she categorised as being too much was not enough to constitute an objectively large amount.
In fact, the portions she described as being too large were minimal.
After meeting with Belinda and her parents individually, they were delivered feedback as a family.
Belinda was diagnosed as having anorexia nervosa and it was recommended that she commence
family-based treatment immediately.
The family arrived for their first therapy session and Belinda’s sister, Jessica, attended the session.
Although initially being reluctant to be involved in the sessions, Jessica found them to be informa-
tive and helped her understand why Belinda behaved the way she did. Jessica also found it helpful to
gain an understanding of her sister’s troubles and how she was able to support her.
The family received 18 sessions of family-based treatment with the family-based treatment clini-
cian over six months, receiving four sessions within the first two weeks, and then weekly sessions for
the first three months of therapy. Sessions were then spaced out every two to three weeks to enable
the family to prepare for the end of treatment.
Anne and Jacob chose to take time off of work during the first phase of therapy and Belinda was
kept from school. Although this placed financial stress on the family, they reasoned that having the
time off now might prevent them from having more time off in the future. This enabled Anne and
Jacob to supervise all of Belinda’s meals and support her when she became distressed. It also allowed
her parents to prevent her from exercising. This enabled Belinda to gain 1 kilogram per week in the
first four weeks of the intervention and her family noticed a slight decrease in her anorexic behaviours.
 Eating Disorders 377

The next eight weeks of phase one were focused on weight gain and addressing the difficulties they
encountered with re-feeding.
After three months of treatment, Belinda was allowed to return to school for half the day and
was then taken home for lunch. Belinda was also allowed to prepare her own breakfast during
this time and have her morning snack at school. As her weight was maintained throughout this
process, Belinda was then able to return to school full time and was no longer supervised at
lunch times. The family had planned that any weight loss would result in returning back to half
days at school.
Throughout phase three, the focus was on a review of adolescent development, how the eating
disorder impacted this process, preparation for treatment ending, relapse prevention and helping
Belinda to become more independent.
Treatment was concluded within the prescribed 18 sessions. By this time, Belinda had been
weight restored and had resumed exercising in a healthy way. She no longer felt the need to
restrict her portion sizes and was able to eat a wide variety of foods, including meat. Although
she was still adjusting to her new body shape, she did not feel that she needed to lose weight.
She was no longer preoccupied by food and calories, and had become more social and actively
participated in family life.
fanbiekey 2)THUS ae weit) ltt lya Ds CRY
Summary

e Anorexia nervosa is characterised by: a) inability to maintain an appropriate body weight for
age and height; b) an intense fear of weight gain or becoming fat; and c) a distorted sense of
body weight or size, or denial of the seriousness of low weight
e Bulimia nervosa is characterised by frequent episodes of binge eating, followed by unhealthy
compensatory behaviours aimed at preventing weight gain that occur on average once a
week for three months
e The most common treatments for adolescents with AN and BN include family-based treat-
ment, individual adolescent-focused therapy, and cognitive-behavioural therapy

Reflective Questions

1. Celebrations and religious festivals are usually centred around food and eating. How do
you think someone with an eating disorder would cope in these situations? What strate-
gies could someone with an eating disorder adopt to help them cope with a difficult
situation such as this?
378 The Handbook of Counselling Children & Young People

. Eating disorders in childhood and adolescence have the potential to disrupt physical
development. What do you think the social and emotional consequences of having an
eating disorder during this time are? Would these create long-term problems?
. How do you differentiate healthy exercise from exercise as a symptom of an eating disor-
der? How much exercise is too much?
. How much do you think people know about eating disorders? Are there any miscon-
ceptions they might have about people who have eating disorders? How would you go
about addressing these?
. How would having a child or sibling with an eating disorder impact on the lives of family
members? What are some ofthe difficulties family members would face?

& ¢

Learning Activities

1. What factors influenced how you felt about your body as a child and then as an adoles-
cent? How did it change as you got older?
2. How would your feelings compare with a child or adolescent with an eating disorder?
3. One of the primary aims of FBT is weight gain. Individuals with AN often perceive
themselves as needing to lose weight. Imagine how someone who views themselves
as needing to lose weight may react and feel when told that they need to gain weight.
4. One challenge that parents of children with an eating disorder experience is under-
standing the behaviour of their child in relation to food and eating. One aim of FBT
is to help the parents externalise their child’s illness and understand that their child’s
behaviour is a result of the eating disorder. How might you describe an eating disorder
to parents to help them understand their child’s behaviour?
5. Has your understanding of eating disorders changed after reading this chapter? If so,
how has it changed?
% .

Further Reading

Dare, C. and Eisler, |. (1997) ‘Family therapy for anorexia nervosa’ in D.M. Garner and PE. Garfinkel
(eds), Handbook of Treatment for Eating Disorders. New York: The Guilford Press. pp. 307-24.
A detailed description of family therapy for adolescent AN by the founders of this approach.

Gowers, S.G., Clark, A., Roberts, C., et al. (2007) ‘Clinical effectiveness of treatments for anorexia
nervosa in adolescents: Randomised controlled trial, The British Journal of Psychiatry, 191 (5):
427-435.
 Eating Disorders 379

The largest randomised controlled trial (RCT) for adolescent anorexia nervosa to date. The authors
demonstrate that specialist inpatient re-feeding is no better than outpatient treatment.

Le Grange, D. and Lock, J. (2007) Treating Bulimia in Adolescents: A Family Based Approach. New
York: Guilford Press.
A detailed treatment manual for clinicians. This text is suitable for clinicians who seek guidance
how to conduct a course of FBT for adolescents with BN.

Lock, J. and Le Grange, D. (2012 [2001]) Treatment Manual for Anorexia Nervosa: A Family-Based
Approach. 2nd edn. New York: Guilford Press.
This is a detailed clinicians’ manual of FBT for adolescent AN. This is the second edition of this
manual, and provides detailed guidance about implementing FBT for AN.

Lock, J., Le Grange, D., Agras, W.S., et al. (2010) ‘Randomized clinical trial comparing family-based
treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa’,
Archives of General Psychiatry, 67 (10): 1025-1032.
The largest RCT, to date, of FBT and AFT for adolescent AN. This study provides robust support of
the efficacy of FBT for adolescent AN.

Russell, G.F., Szmukler, G.l., Dare, C. and Eisler, |. (1987) ‘An evaluation of family therapy in anor
exia nervosa and bulimia nervosa, Archives of General Psychiatry, 44 (12): 1047-1056.
The first RCT for eating disorders involving two psychosocial treatments.
This seminal work provided the
foundation for the future involvement of parents in the recovery of their ill offspring with AN.

Additional Reading

Alexander, J. and Le Grange, D. (2010) My Kid Is Back: Empowering Parents to Beat Anorexia Nervosa.
London: Routledge.
Collins, L. (2005) Eating with Your Anorexic. New York: McGraw Hill.
Lock, J. and Le Grange, D. (2005) Help Your Teenager Beat an Eating Disorder. New York: Guilford Press.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially Modules CMD 02: Participation
and Empowerment; CMD 03: Legal and Professional Issues; CMD 04: Cultural Competence;
CMD 05: Initiating Counselling; CMD 07: Relational Skills; CMD 08: Therapeutic Skills: CMD 10:
Concluding Counselling.
A website that is educational for parents and practitioners: www.maudsleyparents.org.
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 Part 4
Practice Settings
 Health and Social Care
Services
Barbara Smith, Sue Pattison and Cathy Bell

This chapter includes:

e Practice and policy and the development of child-focused services

e Working with children in care including adopted children
e Child and Adolescent Mental Health Services (CAMHS)

Introduction

The work of the professional counsellor takes place in a diverse range of practice set-
tings and covers the main modalities and interventions such as talking therapies in the
client-centred/humanistic, cognitive-behavioural and psychodynamic approaches and
play therapy/therapeutic play, filial therapy and other creative approaches. This chapter
looks specifically at the practice contexts of health care and social services where coun-
sellors are employed to work with children and young people, either directly through
the statutory organisations, National Health Service (NHS) and local authority (LA) or
sub-contracted from another service provider such as a charitable trust or agency on an
employed or self-employed basis. Although the range of health and social care services
are similar across the various parts of the UK, they may be organised and referred to dif-
ferently in England, Northern Ireland, Wales and Scotland and be informed by country
384 The Handbook of Counselling Children & Young People

specific legislation and policies. Counsellors are advised to familiarise themselves with
the policies, practices and legislation most appropriate to their context. Professional
counselling bodies such as BACP are a good source of information or signposting.
As practitioners, we are familiar with a range of sub-contexts within the health and
social care services, and we share with you our knowledge, skills and experience from
our work with some of the most vulnerable children and young people. As authors we
have learnt much about each others’ career histories from the process of story sharing.
Our joint career histories include counselling and psychotherapy, teaching, researching,
writing, social work, nursing and health visiting. Our knowledge, skills and experience
are brought to this chapter in a way that you, the reader, can find accessible and can
engage with in ways that enable you to inform and enhance your own practice. The
scope of ‘health and social care services’ is vast and it is not possible to cover it all in
relation to the work of counsellors.

Practice and Policy: The Development of Child and

Young Person-Focused Services

In developed countries, the notion of childhood has shifted from one of extreme
vulnerability and lack of consequence to a position strengthened by human rights
legislation and policy, for example, the United Nations Convention on the Rights of
the Child (UNICEF, 1989). In the UK, the National Health Service (NHS) was set up
to address the needs of the post-war population and included welfare strategies to
enhance the physical growth, development and health needs of mothers, babies and
children (Webster, 2002). Children’s developmental progress became of interest to
parents and professionals and could be measured and charted and used by UK Local
Authorities as a yardstick for the quality of care provided by parents. Child abuse and
neglect were studied and legislated for, leading to the responsibilities and powers that
Local Authorities now have in relation to the welfare of children and young people.
Alongside this, child guidance clinics attached to hospitals and in the community grew
in number to provide for the needs of ‘difficult’ children and young people, those with
behavioural problems and/or special educational needs such as physical or learning
disabilities (Sampson, 1976). The responsibility for children and young people with
‘special educational needs’ developed and became part of political discourses around
human rights and the concept of inclusion gained political credibility leading to the
health and social care landscape of anti-discrimination, access to services for all and
addressing the needs of diverse and marginalised groups (MacBeath et al., 2006).
Mention health and social care services to a counsellor working in any sector or
from any modality and a variety of responses are liable to be solicited. These may range
from frustrated responses such as: “There are not enough resources, therefore, it’s a
 Health and Social Care Services 385

postcode lottery’ and ‘Even though my young clients are living in extremely neglectful
homes, nothing is ever done about it’ to grateful comments such as: ‘I’m so glad there
is support out there for vulnerable young people. The response will depend on the
individual’s experience, and yet when the UK National Health Service was set up in
1946 it was hailed as being free for all from the ‘cradle to the grave’ at the point of deliv-
ery. With health and social care being a devolved matter within the United Kingdom,
despite shared values and similarities in legislation, policy and practice, considerable
differences are continuing to develop within the systems of each of the four countries
(nations) that make up the United Kingdom: Scotland, Wales, Northern Ireland and
England.
As with any counselling context, it is useful for counsellors to have an understanding
of what is meant by health and social care services. However, in view of the statutory
nature of these services and their powers and responsibilities in respect of safeguard-
ing children and young people, a good working knowledge of these services and how
their work is impacted is essential for counsellors. For discussion on safeguarding see
Chapter 17: Law and Policy.
Across the countries of our world, access to health care will vary. This is largely
influenced by each country’s social and economic condition and the health policies in
place. Some countries see health care distributed among market participants, whereas
in others planning is made more centrally among governments or other coordinating
bodies. The four nations of the UK can be seen as microcosms in relation to global
health and social care systems. According to the World Health Organization (WHO)
a well-functioning health care system: “Requires a robust financing mechanism with
a well-trained and adequately paid workforce, reliable information on which to base
decisions and policies and well maintained facilities and logistics to deliver qual-
ity medicines and technologies’ (World Health Organization Health Systems: www.
who.int/topics/health_systems/en/). For the counsellor who works with children and
young people this means they would be well advised to know about and have some
understanding of how the health and social care services which surround that child
and their family work in order to operate safely and ethically. In order to achieve
this some health and social care authorities will purchase the services of counsellors,
art therapists, play therapists, music therapists and others directly to enable a useful
resource to add to an existing or developing multi-disciplinary team. This approach
helps to provide balance in relation to knowledge and experience. In other instances
local services may be put out to public contract and counsellors and therapists could
be employed by the local agency or charity in the voluntary or community sector that
successfully applies for and is granted the tender for a specific service delivery. This is
another service building approach that can lead to shared knowledge and experience.
The lone counsellor may be vulnerable as a practitioner and their practice less encom-
passing in terms of knowledge and experience.
386 The Handbook of Counselling Children & Young People

The modern approach to health and social care requires groups of trained profes-
sionals and para-professionals to come together as interdisciplinary teams in order to
provide an all-round service to the child and family, known as multi-agency working
(Edwards et al., 2009). The cost of providing such care can be high as the number of
‘problem families’ in the UK rises in relation to socio-economic factors such as high
unemployment and increasing demands on health care systems due to changing demo-
graphics and greater expectations. In many nations health care alone, according to
OECD data, can use up to as much as 23 per cent of a country’s expenditure.
For ease of access in deciphering the maze of health and social care services within
the United Kingdom and to enable international contexts to be compared by the reader,
we will look at services as they fit into the categories of primary, secondary and tertiary
care. Although no longer formalised categories of care in the UK NHS (now referred to
as Tiers 1-4), they provide the reader with a sense of perspective across the levels of care
across the range of services. Primary care is the term for those health care services which
contribute to the health and well-being of the local community. It is the first stage of any
journey within health and social care, the first port of call for all who use the health care
system. Such professionals could be a nurse, general practitioner (GP), dentist, counsel-
lor or play therapist depending on which services a local authority or NHS Trust offers
within its primary care provision. In most areas the first contact is the GP, who is the
main referral agent for children and young people outside of the school context. Within
the sphere of mental health services for children and young people, formalised in the
NHS as Child and Adolescent Mental Health Services (CAMHS), primary care fits with
Tier 1 services (see Table 9.1). Generally, secondary care is when a patient needs to see
professionals such as cardiologists, urologists and allied health professionals, for exam-
ple, counsellors, and psychologists. Secondary care is often associated with hospital care
yet a dietician, a counsellor or a psychiatrist may be seen in a local health centre, clinic or
community centre. Secondary care is normally only accessed via a doctor’s referral and
in rare instances by a patient self-referral (equates to Tiers 2 and 3 in CAHMS).
Tertiary care is specialised consultative health care and includes Tiers 3 and 4 CAHMS.
It is usually for inpatients and is reached by a referral from a primary or secondary
health professional. Examples of this are cardiac surgery, advanced neonatal services,
palliative care, and secure or other psychiatric units. It is important for counsellors to
recognise that many types of health and social care interventions take place outside of
health facilities. Food safety services, needle exchange services, professionals who serve
in residential and community settings, self-care, home care, assisted living treatment for
substance misuse are examples of such services. The counsellor may come into contact
in any counselling situation with a child or young person who has input from other
professionals. In the counselling room at times it will be very obvious to the counsellor
that the young client has a physical disability, a communication difficulty or an illness
that requires some form of health or social care support. For example, the child may be
 Health and Social Care Services 387

a wheelchair user or have adapted equipment to carry out everyday tasks. Some of our
young clients may have a physical illness such as diabetes, asthma, epilepsy or childhood
cancer. It may be useful for counsellors to be aware of any physical illness as it can have
a direct impact on the counselling, for example, young people who take medication for
epilepsy on a morning may be more alert in the afternoon and more able to engage with
counselling. Some illnesses can cause tiredness and impact on the ability to concentrate.
In our individual practices we have each had young people in the counselling room who,
due to physical illness, could not have a counselling session in the afternoon as they
were physically too tired. Physiotherapists, occupational therapists, specialist nurses and
social workers specialising in disability could have an involvement with the young client
and a team approach may (though not necessarily) be helpful. A counsellor may notice
a progressive or sudden change in a young person's physical health and be required to
share this information under safeguarding policies or as a specific requirement of
contracts with the organisation through which they deliver counselling.

Working with Children and Young People in Care

At the present time there are about 67,000 children in England looked after by Local
Authorities (Harker, 2012). Looked-after children are those young people who are
subject to ‘care orders’ under Section 31 of the Children Act (1989) or those who are
voluntarily accommodated under Section 20 of the Children Act (1989). Some children
are looked after if they are involved with the youth justice system or subject to police
protection. Some young people are looked after within foster families, while others are
looked after by kinship carers (members of their own extended family) or in residential
homes. This section addresses the particular issues and challenges for therapists work-
ing with these children and their families. What is distinct about this group of children
is that by definition they have been neglected, abused, or are at least dealing with the
traumatic impact of separation and loss.

Common Experiences of Looked-After Children

When we meet any child for the first time for counselling, we are curious about what
brings them into our lives. What's happened? With looked-after children we can safely
assume that this child has experience of social workers, maybe police officers, judges,
case conferences, not to mention what went before - the reasons why these profes-
sionals became involved in their lives. Research by Cleaver et al. (2011) found that
there are particular difficulties relating to parenting capacity that impact on the health
388 The Handbook of Counselling Children & Young People

and development of children at different ages. These issues are domestic violence,
drug and alcohol dependency, mental illness (the toxic trio) and learning disability.
They found that it is the ‘multiplicative impact’ of a combination of these different
problems that are more likely to be harmful and that bring children into the care
system. What we have learned about the impact of domestic violence on children
and young people is that like other abused children, they may be dealing with symp-
toms of PTSD - dissociation, numbness, disturbed sleep, lack of concentration and
withdrawal. They may be experiencing flashbacks, memory problems and difficulties
relating to other children (Graham-Berman and Levendosky, 1998). Children unable
to deal with these distressing feelings will often ‘act out’ all manner of behaviours in
their attempt to survive, bringing them to the negative attention of teachers, police
officers and other professionals. As a result, placement stability in care can be dif-
ficult, some children moving placements as many as three times in one year (Munro
and Hardy, 2006). Children in care frequently suffer chronic low self-esteem and self-
confidence. Fahlberg (1991) tells of the risk of problems with attachment in the early
years where poor parenting through drug and alcohol use or mental illness can cause
infants to see themselves as unloved and unlovable. Golding (2008) suggests an inabil-
ity to regulate emotion is a consequence of a difficult infancy and early childhood,
often resulting in a range of distressing emotional, psychological and behavioural
problems (Golding, 2008).

Therapeutic Work with Children in Care

Given the particular levels of distress of children in care it is important for counsel-
lors, social workers, teachers and carers to have knowledge and understanding of
attachment difficulties and their ensuing problems. Gerhardt (2004) writes about what
neuroscience offers in understanding the internal world of the child, promising greater
insight into how we can support children’s emotional life in the future. In her work on
the importance of affection in shaping a baby’s brain, Gerhardt (2004: 49) speaks of the
powerful impact of a disapproving or rejecting look, which causes ‘a sudden lurch from
the sympathetic arousal to parasympathetic arousal, creating the effects we experience
as shame — a sudden drop in blood pressure and shallow breathing. Some children
have been raised in cold affectionless environments and need a reparative therapeutic
process to help them to heal, not just with a loving therapist, but with all adults who
they come into contact with. For this reason much of the therapeutic work undertaken
with children in care involves foster carers and/or perhaps birth family members. As
well as the different individual play therapy approaches discussed elsewhere in this
book, some authors have written specifically for children traumatised in early child-
hood and who have attachment difficulties. A specific role for a counsellor working
 Health and Social Care Services 389

with local authority personnel would be to offer consultation and training to social
workers, teachers and carers. Some of the therapeutic approaches used in working with
looked-after children are outlined in the following sections.

Attachment-Focused Parenting

Attachment-focused parenting, developed by Dan Hughes (2006), fosters a relation-

ship between carer and child in which the child experiences a ‘safe haven’ and where the
child feels physically, psychologically and emotionally safe. Hughes uses the acronym
of PACE to describe his model - Playfulness, Acceptance, Curiosity and Empathy. The
idea is to facilitate parents to engage the child expressively and playfully giving the child
the message that the relationship is stronger than any small irritations. Hughes’ model
suggests that an attitude of acceptance and empathy enables the adult to co-regulate the
child's emotional state, enhancing the child’s own capacity for emotional regulation. An
attitude of curiosity and wondering enhances the child’s capacity to construct meaning
(Golding, 2008). This is supported by the ground-breaking work of Schore (2010) who
has integrated attachment theory and neuroscience. He describes how our right brain
hemisphere regulates emotion and processes our sense of self, suggesting that what
we (counsellors) communicate unconsciously is essential to our clients’ recovery from
early childhood trauma. The PACE model then, is based on facilitating carers to offer
therapeutic environments for children in their care. Often carers have suggested that
children’s difficult behaviours happen suddenly ‘as if a switch had been turned on - the
carer begins to recognise the onset of a child’s overwhelming feelings.

owt
Case Study Katy
Katy, aged six, came for counselling with her grandmother, Joan, her kinship carer, because Katy
would on occasions scream abuse and scratch and punch her Gran ‘out of the blue’ When this hap-
pened, Joan found it difficult to deal with Katy — she was hurt and angry and would threaten that Katy
would have to go and live with someone else — exacerbating Katy’s anguish and insecurity. Joan’s own
distress was getting in the way of her helping Katy to learn how to deal with her difficult emotions. It is
hard to empathise with a child who is raging at you. Using an attachment focused parentin g approach
Joan learns that Katy’s angry displays are not about her — they are the only way Katy knows how to get
through the next moment/ten minutes/hour/day. Joan needs support to stay grounded and loving
when Katy is suffering in this way by learning about attachment and what is behind Katy’s behaviour.

a (Continued)
i
 390 The Handbook of Counselling Children & Young People

(Continued)

Over time, Joan came to develop the PACE skills, offering Katy a containing experience (as was offered
to Joan by the counsellor) and Katy’s distressing episodes became less frequent and less intense. Katy
is now able to deal with her feelings by asking for her needs to be met and asking for help when she
is feeling upset.

Theraplay

Another way of supporting children within their foster placements is through Theraplay,
a model designed to build and enhance attachment (Booth and Jernberg, 2010). This too
has a basis of playful interaction between children/young people and carers, and focuses
on four essential qualities of the relationship between parent and child — structure,
engagement, nurture and challenge. The notion of Theraplay was originally developed
by DesLauriers and Carlson (1969) to work with children with autism. Their research
focused on five severely autistic children over a one year period. Applying the method
(now known as Theraplay), personality and socialisation qualities improved, as was
evidenced by parent, clinic and therapist ratings. Emphasising the importance of an
emotional connection between the child and parent/caregiver, the work differs from
the work of Hughes (2006) in that the play is structured to attend to specific difficulties
the child may be having. For example they give specific examples of ways of work-
ing with children and young people with autistic spectrum disorder, those who have
experienced complex trauma and young people who have been adopted. Such specific
difficulties are met with a range of specific Theraplay activities to enhance children’s
functioning, but particularly to enhance the young person's attachment relationships.
Counsellors may work with children, carers and others involved in the Theraplay
approach, both supporting and contributing to the approach.

Life Story Work

It is well documented that placement instability adversely affects the psychosocial

development of children in care (Lewis et al., 2007). Furthermore, as previously men-
tioned, some looked-after children can have as many as three placements in the course
of one year (Munro and Hardy, 2006). Shockingly, research by Ward and Skuse (2001)
found that in a long stay sample of 242 children and young people, 28 per cent had three
or more placements and 3 per cent had six or more. This may be because placements
are often unplanned and crisis-driven, or because of a shortage of carers and unfilled
 Health and Social Care Services 391

social work vacancies. When a child is moved, they not only leave their placement, but
they have to deal with a range of changes of school, friends or even separation from
siblings. When a child has been in care for some years, particularly when they have
had several placements, they can become confused about their past, and memories of
different places and people become blurred. One child said ‘I lived with John and Sue
when I was five or it might have been when I was eight ... I think I had a dog named
Boudie and I think I had a sister’.
A life story book is not only a record of places, people and events in the child’s life, but
an opportunity to process painful feelings about incidents and endings along the way.
While some people consider the life story book as an ‘end product’ with important factual
information for the child, it can also be a therapeutic ‘journey’ in which the child makes
sense of why they came into care and why they moved from one fostering or residential
placement to another. Ifa child is not clear about why they have moved, they may experi-
ence a move as a rejection. The book is put together over a period of time covering the
time from birth until the present day. It often takes the form of a scrap book with copies
of birth certificate, photographs of birth family members and stories and photographs
of foster families. Counsellors and play therapists within the local authority context, or
social workers using counselling as part of their wider role may use life story work exten-
sively to help children and young people build self-esteem and confidence, develop a
sense of identity, and express and deal with difficult emotions and psychological distress.

Case Study James

a
James, now aged 12, had been adopted at age two, but sadly the adoptive placement broke down
because his adoptive parents could not cope with James's behaviour — biting, hitting, swearing, etc.
James's infancy had been troubled, leaving him unable to regulate his emotions and with a confused
sense of self. He had had numerous short-term placements in foster care and was eventually placed
with long-term foster carers. It was important that James did not experience the same rejection as
with his birth mother and adoptive parents, and so life story work began within a contracted coun-
selling context. Over several months of counselling, using a child-centred approach and creative art
materials, James came to understand why his birth mother had been unable to take care of him. An
important piece of information for James was that while his mother struggled with addiction prob-
lems, she had fought hard to keep him. He had not been rejected! — he had been taken into care for
his protection and survival. He was able to talk about his anger with his counsellor and social worker,
and at the same time hear about the impact of addiction on people's ability to look after a small child.
In making sense of the various moves he had been subject to, he learned the difference between
short term and long term foster placements, and how those foster carers had loved and cared for
conte
 392 The Handbook of Counselling Children & Young People

=
(Continued)

him while the social worker was finding the right long term placement for him. He
was able to cry about people he missed and also talk about some that he hadn't been
keen on. During this process, the counsellor listened with empathy and compassion
and answered some difficult questions about adults and how they can sometimes get
it wrong for children. As James began to understand more fully the reasons for the
multiple moves in his young life, he came to see that there was nothing wrong with
him and that his behaviours were a perfectly understandable reaction to distressing
feelings that he didn’t know what to do with. Making sense of his past enabled James
to be more self-accepting and develop a stronger sense of identity. James regularly re-
visits his life story book and will need to re-visit it with an adult, perhaps a counsellor,
a social worker, or carer when his questions need to be answered in ways appropriate
to his different developmental stages.

Therapy with Adopted Children

Since 2005, when the Adoption and Children Act 2002 was fully implemented, the law
specified that only those therapists who are registered with Ofsted as part of an adop-
tion support agency (ASA) can offer specific adoption services. Therefore, counsellors
who work with clients for whom adoption is the main focus of therapeutic work are
employed by registered adoption agencies.
Rogers (2010) highlights the work of therapists working with adopted clients. She
suggests that a therapist working in the field of adoption needs ‘to be able to bear the
weight of all of the losses and grief of the adopted clients, adoptive parents, birth rela-
tives and prospective adopters — and survive its enactment in the therapeutic space.
In addition, she argues, the early experience of rejection can lead the client to play out
their pain in the transference relationship. Further, if and when intimacy is established,
there may be a premature ending to the therapy; to risk intimacy might lead to further
unbearable experiences of rejection and abandonment.
Adopted children have often had a turbulent history before being looked-after in
the care system. These early traumatic experiences of loss and separation can lead to
children developing attachment disorders, behavioural difficulties and developmental
problems which can disturb them long into adult life. The naive expectation that the
provision of a loving home with new loving parents will lead to instant stability has long
been questioned. Adopted children often believe that they are somehow fundamentally
flawed. This is true for many clients from a range of backgrounds, but there is
 Health and Social Care Services 393

something about the experience of being adopted that gives the child hard ‘evidence’
that they were not wanted, not loveable enough or not good enough.
Rogers (2010) highlights the different areas of expertise required to work as an
adoption therapist, including understanding issues of rejection, reunion and life story
work. Themes of identity and belonging are frequently present — those often ‘taken-
for-granted’ issues of religious background, blood relatives, cultural history and genetic
and medical history cannot be assumed for many adopted children. ‘It is the not know-
ing that results in many adoptees having burning questions about who they are; the
circumstance behind their placement, their birthparent and ultimately why they were
given up (see: www.counselling-directory.org.uk/adoption.html).
Young people who have been adopted may need support in dealing with the emo-
tional impact of tracing birth parents and the experience of reunion — both positive and
negative. Birth parents may have a new family and the client has to deal with the fact
that these other children were ‘kept’ again reinforcing long held beliefs that it is their
‘badness’ that made their parent give them up. As well as intense feelings of loss and
grief then, strong feelings of anger and shame may also be present. Approved Adoption
Counsellors are registered with Ofsted, and are subject to regular inspections. This
challenging and rewarding work needs therapists who are resilient, knowledgeable,
reliable and willing to commit to the ‘long haul:

The Work of Specialist Child and Adolescent Mental Health

Services (CAMHS)

The information provided in the following sections on Child and Adolescent Mental
Health Services (CAMHS) is as accurate as is possible in an ever-changing UK NHS
environment, giving a flavour and overview of how services are organised as provid-
ers of mental health care for children and young people. CAMHS are NHS community
and hospital-based mental health services for children and young people. The work of
community CAMHS teams was previously undertaken by the local authority child
guidance clinics, until 1995 when the Together We Stand document was published
(NHS Health Advisory Service, 1995), offering a coherent planning, delivery and
evaluation strategy for children’s mental health. The document introduced the cur-
rent four tier CAMHS framework.
Tier 1 is provided by universal services such as in-school counsellor, teachers,
health visitors and GPs, who are not necessarily specialist mental health practition-
ers but may have some mental health knowledge They offer advice and support
including mental health promotion and are able to signpost young people to other
more specialist services. Tier 2 are those professionals working in community and
394 The Handbook of Counselling Children & Young People

primary care settings and may be counsellors, play therapists, primary mental health
workers, paediatric clinics or psychologists. They may guide and support families,
train Tier 1 workers and identify young people with more severe or complex needs.
Counsellors may be employed by CAMHS to provide care and support in the school
or CAMHS based contexts. Tier 3 CAMHS provide a multi-disciplinary approach in
a community mental health clinic. The team usually consists of specialists such as
psychiatrists, psychologists, family therapists, mental health practitioners, counsel-
lors, play therapists and nurse therapists. Tier 3 services support those young people
with severe, complex and persistent disorders. Typically, a Tier 3 service will take
referrals from GPs, school counsellors, teachers, school nurses, social workers when
young people have symptoms of mood disorders such as depression, and anxiety dis-
orders such as social anxiety disorder, post-traumatic stress and phobias. Specialist
CAMHS workers may also see children and young people who need assessment
for autistic spectrum disorder (ASD), attention deficit and hyperactivity disorder
(ADHD) (although this latter condition is as likely to be assessed by the commu-
nity paediatric team). Tier 4 CAMHS services are for children and young people
with serious mental health problems, provided by highly specialised day units, outpa-
tient teams or inpatient units. CAMHS also offer targeted services for young people
with learning difficulties, physical illness, behaviour difficulties or children in care,
although the scope of provision may differ in different parts of the UK and change in
response to NHS objectives. Counsellors may act as referral agents to CAMHS or be
part of specialist service provision.

Working with Risk

Working with risk is relevant to all contexts of counselling children and young people
(see Chapter 17: “Law and Policy’). However, the elements of risk may be higher in
children and young people who have been referred to specialist CAMHS, though this
cannot be assumed. Tier 3 specialist CAMHS workers often carry a caseload of a wide
range of difficulties, including young people who are persistently self-harming. This
might include overdosing on medicines, using ligatures dangerously, and often cutting
their skin, sometimes quite deeply. Similar risky behaviours may also be seen in other
counselling contexts, for example, secondary schools.
Favazza (1989: 143) suggested that ‘of all disturbing patient behaviours, self-muti-
lation is the most difficult for clinicians to understand and treat’. A range of negative
emotions are expressed by practitioners dealing with young people who self-muti-
late, but particularly powerlessness, helplessness and inadequacy (Favazza, 1989;
Spiers, 2001; Sanderson, 2006). In a study undertaken by YoungMinds and Cello
(2012), as many as one in 12 children and young people are believed to self-harm,
 Health and Social Care Services 395

inpatient admissions increasing by 8 per cent. Intensive therapeutic intervention,

including outreach work and telephone contact is recommended by the National
Institute for Health and Clinical Excellence (NICE) for the treatment of self-harm,
particularly when a young person is at risk of repetition. They also emphasise the
importance of follow-up on missed appointments to lessen risk. In the YoungMinds
and Cello report, young people identified unmet needs in being able to speak openly
to a range of professionals, finding support and advice from the adults around them.
Although self-harm behaviours are common in other counselling contexts when
working with children and young people, the severe or more dangerous types of
self-harm tend to be referred to specialist CAMHS.
According to the Royal College of Psychiatrists (2012) there are a range of rea-
sons why young people harm themselves, but essentially it is a way of coping with
distressing feelings building up inside. Feeling desperate with nowhere to turn may
lead a child to feel helpless. This might lead to a young person cutting themselves
to relieve the tension and to feel more in control. Others have reported feeling guilt
and shame; self-harm being a way of punishing themselves. Some report traumatic
events where they have disconnected from their bodies, the self-harm enabling them
to feel alive (Royal College of Psychiatrists, 2012). It is important to distinguish self-
injury from suicidal intention, and Connors (2000) claims that self-injury has been
misperceived and confused with suicidal intent. Self-injury is often indicated when
young persons have a serious mental health problem, have been subject to abuse or
rejection, are depressed or have an eating disorder, along with alcohol and drug prob-
lems which indicate increased risk. Often, self-harm is triggered by arguments with
family or close friends (Royal College of Psychiatrists, 2012). While self-injury is
often serious, it is important to know that suicide is more likely when a young person
is depressed or has a serious mental illness. CAMHS practitioners assess for previous
suicide attempts, and in particular if ayoung person has a plan about dying in a situ-
ation where they cannot be saved. Having a relative who has killed themselves also
increases risk, and if a young person is intoxicated or under the influence of drugs,
they are at particular risk.
Part of the care plan for young people in this category is to ascertain the level of sup-
port within the family and to help them to find new ways of expressing their distress.
Advice to parents to lock away pills or sharps is part of helping to keep young people
safe until the therapeutic work can get underway and until their mood improves.

Specialist CAMHS and Cognitive-Behavioural Therapy

Many of the interventions recommended by NICE include an element of cognitive-

behavioural therapy (CBT). For example, depression, anxiety disorders, PTSD, ASD
 396 The Handbook of Counselling Children & Young People

and ADHD. CBT theories and interventions are addressed in Chapter 4 of this volume
and therefore it is not necessary to detail the approach here. However, it is important
to recognise ways in which CBT is utilised within CAMHS. School age children with
a diagnosis of ADHD, for example might be offered some CBT and/or social skills
training, as well as parents being recommended parent training/education programmes
(NICE, 2008). In addition, CBT has been shown to be feasible for children with ASD
having a verbal IQ of at least 69 (Scottish Intercollegiate Guidelines Network, 2007).
It is also recommended as a first-line treatment for moderate to severe depression
in children and young people (NICE, 2005). Below is an account of a piece of work
undertaken over three sessions with an adolescent boy who had walked with crutches
or had used a wheelchair for the past 18 months, unable to walk unaided.

Case Study Jack

Jack, aged 15, was referred from the Children’s Hospital, having been admitted for a range of tests
to ascertain reasons why he could not walk. He had not walked unaided for 18 months. His symp-
toms were not medically explained and may have been psychologically based. When he came for his
first session, Jack used crutches, and leaned heavily on the walls and banister to keep him upright.
He lumbered up the stairs awkwardly and appeared really sad. His parents were extremely worried
about Jack, fearful that he would not be able to walk again.
On discussing Jack’s ‘condition’ he himself suggested that it might be for ‘attention’ | felt moved
by Jack's ‘take’ on his situation and shared my own experience of the attention | had received when |
used a wheelchair having fractured my foot. However, Jack's insight did not help him to get up and
walk, so we agreed to take a CBT approach (Speckens et al., 1995). | asked Jack what would happen if
he tried to walk without his crutches and why. He said that it was like someone had cut a tendon at
the back of his knees and he would collapse. We talked about the power and strength of the muscles
in our legs and about the recent achievements of Olympians. We then discussed some ‘exposure’
homework to do with his dad at home - a chart recording Jack's progress — day one, Jack would take
three steps with the help of his dad. On day two he would take five steps, until he had done ten steps
by day seven. When Jack came back the following week, | asked about the homework, but it had not
been successful. They were a little despondent and feeling hopeless.
Having a background in outdoor therapy (see Chapter 8) |asked ifthey would be willing to come to the
nearby park with me for some behavioural experiment work in the form of graded exposure. Risk was
clearly an issue, as Jack could have fallen and hurt himself. However, the alternative was to refer him
to Tier 4 services (hospital) and both agreed that we should head for the park, acknowledging there
eis risks involved. =)
 Health and Social Care Services 397

We identified two large trees about 50 yards apart. On the first ‘walk’ he held on tightly to his apse
hands and staggered towards the tree leaning heavily on his father. | encouraged and supported
Jack, telling him he was strong and safe. By the fourth ‘walk’ he was more stable, but still holding on
tightly to his dad. | encouraged him to hold more lightly to his dad, which he did. As his confidence
grew, Jack held more and more lightly to his dad. Then | supported Jack on his walks between the
trees, inviting him each time to lean less and less on my support. On the last ‘walk’ Jack was just
touching my finger very lightly ‘like a butterfly, and | told him | was going to take my hand away. He
walked confidently to the tree, then back to the office. He has not used aids since.

By

lerease Study Poppy )

CBT was also helpful with Poppy, a little girl aged eight, who had a strong aversion to foods other
than yogurt, biscuits and crisps. Poppy was a bright, articulate child, whose parents were loving and
supportive, but who were increasingly concerned about Poppy’s long term health and social life.
She had begun to have regular blood tests to ensure that her health was not being impacted and
refused to attend children’s parties or family outings to restaurants. When presented with new foods
Poppy would become highly anxious and get into a panic, wanting to please the adults around her,
but crumbling into tears feeling bad about letting people down. She was frightened and phobic, but
wanted to eat. | agreed to undertake some CBT graded exposure work with Poppy, gently exposing
her to increasing amounts and a broader range of food.
Once Poppy had got to know me, | cut and pasted pictures of a range of different foods from
the internet onto a large flip chart. We sat on the floor and gave each food a rating of 0-10. A
score of 10 indicated food she would definitely not want to try. We identified a couple of things
such as cheese and breakfast cereals and spoke about them at length. In the first ‘eating’ session
Poppy tried the smallest piece of cheese you can imagine. She put the cheese to her lips and
began to get very anxious and tearful. It is at this point that the skill of the CBT therapist prevails,
resisting the temptation to say ‘Don't eat it if you don’t want to’ Instead gently supporting — ‘It’s
okay sweetheart, it’s just a little tiny weeny piece of cheese. It’s soft like yogurt and a bit salty like
crisps. Yes, that’s right just put in on your tongue. Brave girl. Well done. Now, if you eat two more
pieces like that you can take two of the Gogo’s out of the box’ The offer of two more Gogo’ (little
plastic figures) was too much to resist. Poppy ate two more tiny pieces of cheese. The next week
she ate some breakfast cereal, then over several weeks toast, then fish fingers at a popular fast
food outlet, until she was able to eat out with her family, serve herself at the buffet on holiday and
attend her friend’s birthday party. ¥
 398 The Handbook of Counselling Children & Young People

Summary

This chapter has provided the reader with:

e An overview of health and social care services beginning with a section that looked at the
development ofchild-focused services through practice and policy
e Information and case study examples of counselling looked-after children, their life experi-
ences and appropriate therapeutic interventions such as therapeutic parenting for Katy, aged
six, and life story work for James, aged 12, to help him gain a stronger sense of identity and
become more self-accepting
e An outline of the role of specialist CAHMS and the case study of Jack, aged 15, is presented
to show how a CAHMS practitioner provided counselling using the cognitive-behavioural
approach resulting in Jack gaining the confidence to walk again unaided
e Examples of therapeutic work, such as the work carried out with little Poppy, aged eight, which
is seen to help her overcome her issues with food

Reflective Questions

1 Read and reflect upon the attachment focused work carried out
by the counsellor working with Katy, aged six, in the first case
study. What stands out about this approach?

The difficulty that Joan, the grandmother has in empathising with Katy when she lashes
out at her is apparent and highlights the difficulties in empathising with children and
young people who are raging at you. The support offered to Katy and her grandmother
alongside each other is central to the therapy.

2 Read the second case study, about James, aged 12, and consider
how you could incorporate life story work into your own practice
with young clients.

Life story work can be incorporated into work, for example in a school counselling
context, or an NHS paediatric setting with children and young people who have lost a
parent to bereavement, or with a terminally ill parent.
 Health and Social Care Services 399

3 How flexible do you see your practice being in terms of offering

sessions to children and young people with chronic illness or
chaotic lives? Reflect upon your service management and whether
this would be possible.

This is a difficult issue due to the structure of many organisations offering support and
services to children and young people. Some services have drop-in slots or keep a selec-
tion of appointments free for young clients.

4 What can the counsellor offer the ‘looked-after’ child or

young person who has experience of instability and frequently
changing foster placements? How might the child experience the
counselling relationship?

Points to consider include the client's previous experience of relationships ending

prematurely and/or badly. They may have experienced several broken relationships
and have deep rooted feelings of loss. By offering a boundaried counselling relation-
ship and a clear structure leading to the inevitable ending, offering some control and
power to the child/young person, for example, in the type of ending they would like to
experience, the ending may be reparative.

EPS I Nl Tae Se et a Sn el tagl sll B ama Val aD ara al dl et elles mae

*
Learning Activities

1. Read further around attachment theory in Chapter 1 of this book and research advances
in neuroscience.
2. Use creative materials, narrative and photographs to look at your own life story. You
may want to carry out this activity in personal therapy if you feel that it may be painful
for you.
3. Audit your practice environment to see if it is user-friendly for children and young
people who may have chronic illnesses or chaotic lives.
4. Look at your own counselling practice and examine service policies around endings and
boundaries with young clients.
é ?
400 The Handbook of Counselling Children & Young People

Further Reading

Cleaver, H., Unell, |., and Aldgage, J. (2011) Children’s Needs — Parenting Capacity: Child Abuse:
Parental Mental IlIness, Learning Disability, Substance Misuse and Domestic Violence. 2nd edn.
London: The Stationary Office.
Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby's Brain. London. Routledge.
Golding, K (2008) Nurturing Attachments: Supporting Children Who Are Fostered or Adopted.
London. Jessica Kingsley.
Hughes, D. (2006) Building the Bonds of Attachment: Awakening Love in Deeply Troubled Children
2nd edn. New York: Jason Aronson.
Improving Access to Psychological Therapies (2012) Available at: [email protected].
YoungMinds and Cello (2012) Talking Self Harm. London: YoungMinds.

Online Resources

Counselling MindEd: http://counsellingminded.com, especially CM1.9: Counselling Across

Services.
 Third and Non-Statutory Sector
David Exall

This chapter includes:

a eneesereeeeeeneeneeneee
e History and background
e Theoretical underpinnings
e Voluntary and statutory partnerships
e Service provision
e Organisational case study
e Research

introduction

This chapter is an attempt to give an overview of services and practice for counsellors
and psychotherapists who work, or wish to work within the voluntary and non-statutory
sector with children and young people. Within this chapter this broad range of organisa-
tions and practitioners will be referred to as the third sector.

History and Background

Charity work and volunteering has a proud history. From the earliest times support for
clients and patients has been delivered through philanthropic ideals. Hospitals, clinics
402 The Handbook of Counselling Children & Young People

and centres have been established over centuries that are primarily funded from trusts
and philanthropy. In terms of therapeutic provision for children and young people,
very often non-statutory work has been in advance of support laid down by statute -
there have been many services offering parental support before CYP IAPT for example.
By its nature this sector is led by individuals who have the ability to shape work as they
see fit, ensuring that children and young people are involved in moulding their service
and so can provide innovative approaches to counselling children. This pioneering also
highlights the dangers of working without clear boundaries and having to speculate
and lead the way in understanding the client/young person. Often no one has trod a
particular pathway and there is a danger of stumbling in this undiscovered country.
Individuals shape and start a service but those that survive cultivate an organisa-
tional identity beyond a single person, indeed a service based upon the vision and drive
of one person can flounder when that person leaves.
In the past ‘counselling’ has often been delivered by a range of people - some who
are experienced and trained counsellors and psychotherapists, others who are trained
to offer active listening, emotional support and mentoring. Very often such counselling
was delivered over the telephone, in groups, home visits or in centres and was some-
times named in different ways such as helping or befriending.
Today counselling has become more professionalised and now most organisations
that offer ‘counselling’ employ those who have core competencies and qualifications,
thanks to the drive of membership organisations such as the BACP and Youth Access.
Services for children and young people have been at the forefront of offering such levels
of quality assurance due to the uniquely vulnerable nature of their clients. However,
many organisations that have adopted counselling and psychotherapy have sprung
from generic services. MIND (founded in 1946), CRUSE and RELATE have in the past,
and do today, offer support for children and families. Agencies such as ChildLine and
Place2Be have adapted and learnt from early pioneers to integrate specialist coun-
selling and therapeutic services which are supported by core competencies which are
added to by specialist training provided by the agency itself.
Large charities will deliver therapeutic interventions in line with their overall stra-
tegic goals. Small organisations need to consider their strategy, even when they have
been established to match a perceived need and focus on the client: someone has seen
that a particular approach seems to work and so builds a model from that perception.
People with such insight are frequently not those with business and other skills and so
in successful organisations they have gathered others around them that support these
strategic goals. Overall many organisations have been initiated by a single person or
small group of people with a vision. It would seem that their ability to thrive is not
solely based upon the efficacy of their direct work with children but by the ability they
have to inter-link with their environment, develop and adapt and to promote the work
that they do.
 Third and Non-Statutory Sector 403

It is not the strongest ofthe species that survive, nor the most intelligent, but the ones
most responsive to change. (Charles Darwin)

Organisations that provide predominantly or exclusively counselling services are poten-

tially vulnerable with some recently closing. Competitive tendering does not always suit
small organisations or those with few strings to their bows. In larger services couns-
elling has become one aspect of provision in most third-sector organisations — for
example, Family Action. Many counsellors wish to offer long-term counselling as their
experience and empathy is with the particular vulnerabilities of their client group and
hold on to this desire as it seems to be ethical to do so. One of the strengths of counsel-
ling in the third sector is that strong individuals have been able to run counter to other
prevailing trends in the landscape of mental health provision.

Theoretical Underpinnings

Much third-sector and non-statutory provision has sprung from teaching and training
in a local area — having been established by counsellors and therapists whose ethical
and philosophical ideas have been forged in their own training. Therefore the eth-
ical underpinning of these agencies has run in parallel with changes in therapeutic
approaches — the rise of humanistic approaches in the 1960s which enabled the empow-
erment of clients, the many changes in psychodynamic counselling and psychoanalytic
thinking, the development and professionalisation of art, play and drama therapies and
the movement towards cognitive and behavioural approaches have all caused changes
that have swept the third sector in its wake.
Many organisations use psychodynamic principles to underpin their work. This theory
has a focus on conflict and a long history of examining childhood to bring insight to
the clinical relationship, and so it is perhaps understandable that such thinking weighs
heavily in child-based therapeutic organisations. Developmental theories around chil-
dren have provided an important foundation for many organisations’ work and these
have often grown from psychoanalytic thinking — the work of Mahler, Erikson, Piaget
and Bowlby to name a few. However, services often do not offer extremely long-term
work due to financial pressure, as well as high-need children being supported by the
statutory sector. Few agencies - although a significant few — will offer counselling for
over a year for example, although many offer ongoing differing forms of support and
forward referral.
As the social agenda towards children and young people has often been on altering
or managing children’s behaviour - especially in early adolescence — there are many
who use cognitive and behavioural approaches. This enables time-effective therapeutic
work to be delivered flexibly within a range of settings. Recent developments in CYP
404 The Handbook of Counselling Children & Young People

IAPT has supported this school of thought and the Department of Health is currently
funding Wave 2 of a national roll-out.
Within and without the therapeutic field there has also been a movement in the belief
in the empowerment of children and young people. Person-centred and humanistic prin-
ciples have grown beyond the therapeutic world but the core conditions of genuineness,
empathy and acceptance are often held as important - usually ‘necessary’ and sometimes
‘sufficient. Humanistic philosophies are also inclusive and so often allow for the integra-
tion of other methods and approaches to working with children and young people.
Many organisations marry different approaches in part to bring the ‘best’ elements of
theory together to match their particular client group. Integrative practice has become
the underpinning for both training institutions and their placement providers. In truth
there is also a need to pursue funding that will support the ongoing existence of their
organisation and so support their clients, and being linked closely to a particular thera-
peutic approach can make an organisation overly reliant on fewer training institutions
and funding streams. Most organisations that predominantly deliver counselling and
support work will have a theoretical underpinning which informs the approach to the
work and provides the foundation stones that can be referred back to when liaising
with partners. It is useful for organisations to consider how coherent these principles
are and how transparent they appear to their service users and other partners.
The BACP has developed a Competency Framework for counsellors working with
children and young people. This framework includes competencies for working within
voluntary and third-sector organisations. The Counselling MindEd curriculum came
online in March 2014 and is part of a broader curriculum for working with children
and young people. It also has core modules related to understanding counselling in the
community context and has modules that address the main theoretical concepts related
to working with children and young people.

Voluntary and Statutory Partnerships

There are few counsellors and psychotherapists who have not worked at some stage in
the third sector. Whatever therapeutic approach or training they may have experienced
and by whatever pathway that they have come to the profession, it is rare to find an
experienced therapist who has not at some stage volunteered or worked in the third
sector. This vast group of small and large organisations has been the breeding ground
for best practice and, on some occasions less good practice, in the field of counselling
and psychotherapy. Statutory services are those services that are laid down by law (stat-
ute) and so are provided by local health and social care trusts and by the Department
for Education in the case of some school-based services. Non-statutory provision has
always complemented or added value to statutory provision — although in many cases
 Third and Non-Statutory Sector 405

it could be argued that the third sector overlaps with statutory provision, offering couns
elling to children with a high threshold of need.
Organisations such as Barnardos have been delivering therapeutic work to children
and young people for years and small agencies have managed to deliver some very
specific and targeted therapeutic support to children and young people - matching
evolving needs in the local communities that they serve.
Statutory services will rely on the third sector to refer children and young people,
such agencies being well placed to identify and work with levels of need in families and
children and holding strong community links and local knowledge. Best practice will
mean this will involve a discussion about the appropriate level of support for the child
or family. Often this supports the statutory Child and Adolescent Mental Health Service
(CAMHS) in prioritising appropriate support for other children. At times this will mean
that the agency is playing a ‘holding’ role for the child before moving on to CAMHS
intervention, where waiting times can be long. At times the therapy will coexist along-
side CAMHS support. So the third sector is both alongside and separate from CAMHS,
needing to understand the language and ethos of the medical profession and psychiatry.
Third-sector organisations need to be able to brush up against other beasts such as
the education system and still maintain their-own voice and identity. The relationship
between a third-sector organisation and the statutory sector is both symbiotic and para-
sitic in nature. The third sector cannot and should not replace statutory provision and
would struggle to function without the referral channels, expertise and overview pro-
vided by those services. However, the statutory system would undoubtedly experience
significant difficulties if third-sector providers were completely removed, and the emo-
tional well-being of families, children and young people would plummet as a result.
In the midst of sometimes difficult social and economic backdrops such agencies
and motivated individuals have delivered a high level of therapeutic interventions
and have pioneered different models and approaches to working with young people,
engaging with the diverse needs of their client group and being able to take the time to
understand the full context of the client’s world. Standards of professionalism are very
high and poor practice rare — in part due to the ‘survival of the fittest’ environment of
non-statutory work. Such provision is often cost-effective due to the use of volunteers
and matches political agendas such as the “Big Society.
However, there are weaknesses in the sector. Typically third-sector provision suffers
during difficult economic times - often being seen as expendable, services that can be
easily and quietly cut, reliance on indirect statutory funding is risky and philanthropic
capital frequently dries up during such times.
The current voluntary and non-statutory landscape looks grim:

e Loss of £3.3 billion from public funders by 2015

e Static growth in individual and corporate giving
e Voluntary services get £13.9 billion from government, 79 per cent is contracts for services
406 The Handbook of Counselling Children & Young People

e About 3 per cent of government funds go to small/medium organisations, the rest to

large charities
e Sustainability weakened —- in 2009/10 voluntary organisations spent 99 per cent of all
incoming resources
e Inflation biting, grants reducing, spending up
e Social investment discussed but not market-ready
e Threat to voluntary services’ independence
e Five per cent reduction in staff in 2010/11
e Volunteering numbers down
e Demand for services has increased
e Big Society policies have failed to engage the voluntary sector as yet.

There are opportunities within this landscape:

e Schools: More autonomy for schools to make their own commissioning decisions
e NHS: New clinical commissioning groups
e CAMHS: Transformation, working in partnership with children and young people to shape
their local services
e ‘Payments by result’ ethos which may suit voluntary and third-sector organisations
e Overall unified outcomes measuring and consistency through NICE guidelines.

In terms of clinical governance and quality assurance of the therapeutic work there
is a wide range of practice within the sector with there being exemplars of clinical
excellence and at times practice that falls short - small agencies in particular being
vulnerable if, for example, they do not have robust child protection protocols or are
not quality assured by professional bodies such as BACP and/or Youth Access, both
requiring adherence to quality assurance standards.
There can be any number of local children’s-based services in any region. Usually
there are youth and children counsellors locally available, working out of small offices
and therapeutic rooms. Larger agencies will have therapeutic practitioners available
and there will always be private counsellors available to support children. However,
there are no consistent or universal referral mechanisms for such agencies or processes
that coordinate their work. These bodies may need to promote themselves and often
‘piggy back their offer as part of a larger whole - for example, working as part of a
school or children’s centre. There may be agencies established to support a particular
part of the community, for example single-parent families. There may be services that
provide for particular mental health issues such as drug and alcohol services. There
may be those that work within a restricted geography that does not match local author-
ity boundaries.
Organisations can also deliver services as part of a wider programme such as
Improved Access to Psychological Therapies (IAPT) and the Children and Young
 Third and Non-Statutory Sector 407

Peoples IAPT (CYP IAPT). Indeed the CYP IAPT is a ‘service transformation project
for Child and Adolescent Mental Health Services’ and has an agenda to be ‘open to
voluntary and statutory services’ and so is designed to bring sectors together and create
coherent pathways of referral. Such programmes will have their own processes and
referral systems as well as a tendering system to enable third-sector organisations to
access funding. These can provide useful support for third-sector organisations but,
as is often the case with commissioning processes, the organisation may need to adapt
its core approach, up skill staff and systems and, more importantly, the agenda may
not match the needs of the children and young people as the individual third-sector
organisation sees it — therefore altering the organisation's core ethos and values. There
is also the issue that these initiatives may not be permanent solutions to organisational
difficulties as political imperatives change.

Service Provision

Counselling can be offered in this sector for any number of sessions - there is no typi-
cal length of counselling across all services, although there may be trends for shorter
sessions in certain client groups. However, there is a strong body of third-sector organi-
sations offering longer term and open ended support including clients that are able to
return to counselling for further sessions after breaks or other interventions. This level
of therapeutic support is difficult to match in the statutory sector unless there is a clear
identification of high threshold need, which often needs to be supported by measurable
difficulties and/or diagnostic criteria. Such diagnosis can take a long time to establish,
as well as children, young people and their families often being resistant to the concept.
In services that are based in schools the average number of counselling sessions rises,
perhaps due to ‘captive’ clients, with this client group likely to have high attendance and
retention rates.
Services tend toward offering a range of services — advice, guidance, support groups,
mentoring, etc. - of which counselling is sometimes a small part. The Stretched to the
Limit Youth Access report notes that 87 per cent of respondents to its online survey
deliver a range of other services including educative and advocacy support. There
will be referral systems that exist between those services and thoughtful discussions
amongst various professionals that support a child or young person. As laid out by the
Fraser Guidelines for younger children, these discussions should include the parents
or carers and, if appropriate, other professionals who will be able to hold in mind the
clients’ individual needs with a broad range of insight and perspective. The strength of
many services for older young people is founded on the ability of clients to self-refer,
often without any other professional contact. If risks and needs are critical, any group
of professionals and carers around a child or young person will investigate all possible
408 The Handbook of Counselling Children & Young People

channels of support for them. This may involve onward referral to CAMHS, social
services, education or other statutory bodies as well as other non-statutory providers.
All involved will have identical obligations in terms of protecting the mental health and
safeguarding of that person, although there may be a range of ways in which the profes-
sionals interpret that duty. In therapeutic terms there is a high level of regard paid to
autonomy, confidentiality and empowerment which may be at odds with other profes-
sionals’ duties. The onus is on all those professionals to manage those dynamics for the
welfare of the client(s). Clarity and transparency is often key. In a scoping report com-
missioned by BACP, The Relationship between Specialist Child and Adolescent Mental
Health Services and Community-Based Counselling for Children and Young People
(Spong et al., 2013), it was highlighted that there is ‘mixed evidence about how effec-
tively working together is achieved; but a strong emphasis from counsellors who were
interviewed on the importance of communication between professionals and clear
pathways of referral supported by both systems and good interpersonal relationships.
The quality assurance of counselling services delivered in the third sector is crucial.
Services deliver using both volunteers and paid counsellors — but all should be profes-
sional in their approach. It is vital to have robust processes for induction, training and
ongoing support for volunteers. In many ways these should mirror processes for any
professionals, although there are some key differences:

e Volunteers may often be counsellors in training. While they may have a vast range of
life experience they will very often need specific support in gathering skills needed for
the client group of the organisation — specialist therapeutic skills and awareness that is
detailed elsewhere in this book. The relationship between a placement provider and the
learning institution should be one that has clear boundaries and clarifies the ethos and
methods of working, as well as re-enforcing core competencies and responsibilities of
the counsellor.
e Many volunteers will also be experienced therapists —- perhaps looking to build thera-
peutic hours or grow specialist skills. These counsellors by their nature are perhaps in
a position to hold a higher threshold of clinical distress in children and young people.
However, care should be taken to support such volunteers to the same degree as less
experienced counsellors
e Volunteers will have slightly different rights and expectations in their role. However, in terms
of delivering a professional service it should always be emphasised that they are working to
the same standards as any other counsellor. In most cases the client should not experience
a different service to that delivered by any statutory body or fully paid professional.

Most counselling services will use volunteers and paid professionals interchangeably. By
using volunteers, services can often be cost-effective - and thus more ‘competitive’ in
service provision, often bringing in leverage funding to the local authority at significant
levels. It should be recognised that by using volunteers the best possible service needs to
 Third and Non-Statutory Sector 409

be built that has a higher level of organisational commitment than is sometimes required
for a service that exclusively uses paid staff, as follows:

¢ Financial and clinical cost of managing a high number of counsellors who perhaps see a
small number of clients per person, especially in relation to induction training and ongo-
ing support
¢ Higher levels of clinical and managerial supervision
e Higher levels of training to ensure consistency
¢ ‘Case-working’ volunteers - coordinating with learning institutions, colleges, etc.

From an organisation perspective there are additional tasks required to enable service
delivery:

e Publicity
e Referral pathways, including self-referral
e Criteria for client access — notably what restrictions exist for referral
e Local knowledge and negotiation with other local agencies

It is worth noting that volunteers delivering counselling may by its nature

de-professionalise counselling. Many organisations are considering how voluntary
counselling should evolve towards an ‘apprenticeship’ model where counselling
delivery is part of a vocational training placement similar to other professions,
particularly those in the health care sphere.

Organisational Case Study

Place2Be and Croydon Drop In both work closely with a range of local partners who
will be connected to their clients in diverse ways. However, due to the nature of these
organisations they can operate differently with their clients. This is an example of dif-
ferent extremes of partner involvement when offering counselling.
Croydon Drop In offers counselling to a young person on a self-referral basis and
can also engage with young people who are actively ‘signposted’ by other agencies; the
core requirement is that the young person wishes to attend. For younger adolescents,
i.e. if under 13, Fraser guidelines and Gillick competence are utilised to ensure that the
young person can access support without parental consent. Very often there will be no
contact with parents, school, police or any other professional or connected organisa-
tions, unless the young person so wishes. This brings with it many advantages in terms
of empowering the young person, hearing their perspective and experience free from
the potential bias of other professionals or parents and is more likely to allow the young
410 The Handbook of Counselling Children & Young People

person to feel secure in boundaries such as confidentiality. There are also risks in terms
of the counsellor not having the full picture and so working in the dark around wider
issues. Therefore there is greater autonomy for the young person, counsellor and the
service, while still working within a structure of safeguarding and child protection but
not restrained by other systems and processes. Croydon Drop In can offer ‘wrap round’
services such as advocacy and practical advice and deliver counselling services to sec-
ondary school pupils within similar boundaries.
Place2Be never offers therapeutic work to primary age children without explicit
consent from parents and various levels of agreement from relevant professionals —
especially school based colleagues. This has advantages of allowing the counsellor to
work in a more systemic way with the client, supports pathways for onward referral
and joins up counselling as part of a wider support package and as part of a team
around the child. Therefore it is more likely that issues of safeguarding can be more
quickly noted and addressed. However, there will be tensions and sensitivity around
confidentiality issues and more scope for outside influences to skew the direction of
the counselling work. While, with careful handling, this is not usually a major factor,
it should be acknowledged that this landscape is likely to make building trust and
fostering empowerment more difficult. Having aligned and linked-up structures and
pathways with partner schools also provides an extra level of accessibility for clients
in a different way to autonomous counselling. Ideally teachers and school staff work
alongside Place2Be personnel to de-stigmatise counselling.
Both these organisations will have strong processes and procedures that ensure safety
in the counselling provision. Both these organisations have referral and assessment pro-
cesses to enable effective counselling delivery, strong procedures of quality assurance
and are well placed to swiftly offer one-to-one counselling in conjunction with other
support services and so have shorter waiting times than statutory agencies. Perhaps the
most important structure is clinical supervision, which is offered in these organisations
at a frequency that exceeds the minimum 1.5 hours a month recommended by BACP.

Research

Many third-sector organisations have built a strong body of practice-based evidence that
can be in many ways unique to them. This provides some fascinating insights to thera-
peutic work but does not always support consistency and the comparing of outcomes and
effectiveness and so can be detrimental to the ability of organisations to access funding
and engage in the commissioning landscape. Recently the importance of evidence-
based practice has become paramount such as is delivered through the CYP IAPT
programme. Practice has been developed based upon evidenced interventions — in that
case, as defined by the NICE guidelines. Whilst this is part of statutory provision there is
 Third and Non-Statutory Sector 411

a drive to include third-sector providers if possible. To add value to statutory provision

third-sector providers at this time need to be able to use the same evidence and so shift to
the use of evidenced-based practice as supported by evidence such as randomised con-
trolled trials (RCTs), which are often seen as the gold standard of measuring outcomes
despite being expensive and time consuming.
COREYP is seen as an effective research tool which is widely used across third-sector
providers and can offer some comparison with statutory organisations — thus providing a
base for demonstrating outcomes and cost effectiveness and so supporting funding and
commissioning for an organisation. Such evidence can also inform the clinical and sys-
temic approach to the work - for example, good outcomes are demonstrated after four
sessions and are not significantly different after 10 sessions — that indicates that short-term
work can be effective in that example. Alternatively it could be shown that counselling
work is more effective (has better outcomes) if the client has received guidance or advice
before the counselling intervention. All of this may shape the way a project is developed.
The recent Targeting Mental Health Support (TaMHS) Initiative was an example of
counselling services being evaluated alongside and as part of other statutory provision.
In that case the SDQ in full was used as the primary tool to reference outcomes and
compare impact. Counselling services compared favourably to other interventions that
were delivered as part of TaMHS.
Current evidence shows that children and young people receiving counselling in
third-sector organisations have demonstrable improvements.
Many organisations such as Place2Be are also striving to find other ways to demon-
strate impact, for example tracking if the counselling may improve capacity to access
learning for a child or have wider long-term implications. If these can be demonstrated
clearly then both counselling and the service itself becomes much more commission-
able and service users and their families will be more likely to trust the intervention.
Many counsellors will be more interested in the use of outcome measurements to
tailor what and how to deliver as part of a service rather than make that service com-
missionable. Good evidence offers this in an autonomous service. What intervention
works best for my clients? How can I use this evidence to improve the experience of the
counselling and generate better outcomes? Do we need to consider our recruitment of
counsellors? Shall we change the ethos of our approach? It may be that on a small scale
research will show that counsellors from a certain training institution are less effective,
for example. Or it may show that offering 24 sessions is markedly more effective (in this
particular service) than offering 12. These are questions that research can provide an
answer to, and if organisations do not have the resources to gather this evidence they
may need to find others who have considered these questions - small organisations
may find the cost of gathering and analysing this data prohibitive.
Third-sector organisations will need to be innovative in proving effectiveness along-
side statutory agencies. Those who are able to match systems and guidelines such as are
 412 The Handbook of Counselling Children & Young People

evidenced through CYP IAPT will be well served in commissioning processes. Others —
perhaps those who engage in longer-term work or innovative models — will need to ensure
that their service quality is demonstrable. Tracking the current temperature of the field of
therapeutic research will remain an important aspect of a thriving organisation.
A third-sector organisation is often like a child itself. Born out of need and
imagination, raised by a few dedicated carers or parents and then needing to find
its place alongside older and more established siblings and adults. For such a child
to grow up and thrive it must learn to adapt to the realities of the current land-
scape, foster new skills and understanding and work alongside others without being
destroyed. It will encounter tough times and conflict. There will be some who think
it is not worthy. It will be asked to prove its worth. It will be asked to make sense and
take responsibility for what it says and does. It must hold on to its core personality
and shape but build strength in the right ways — including knowing when to speak
to others and ask for help.
The evolving landscape of the world of counselling and therapy is changing as much
for children and young people as with any other client group, as in the need to be ready
for meeting clients in their language of communication, telephone, email and online
counselling. The many challenges facing children in the 21st century all add up to an
exciting and dangerous world for third-sector counsellors.

Summary

e The voluntary and non-statutory sector is a crucial aspect of mental health and counselling
provision
e The third sector provides innovative and pioneering approaches and methods of coun-
selling delivery
e The third sector is the training ground for counselling and psychotherapy
e It is important to hold in mind factors both clinical and practical when considering delivering
therapeutic work in the third sector

Reflective Questions

1 For organisations:

1. What is the ethos of your counselling organisation and how does it fit into the wider
systems?
2. Are you re-inventing the wheel? Can you borrow what you need from other organisations?
 Third and Non-Statutory Sector 413

Are you strategic in your approach to the work?

How do you know that your organisation works for your particular clients?
Do your children and young people understand what you do and who you are?
ea
Ye Do you have robust quality assurance processes — would they stand comparison to statutory
Mags
bodies?
7. What evidence, beyond anecdotal feedback, do you have that counselling (and your
method of counselling) matches the needs of your client group?
8. What are the ‘criteria’ for children and young people to access your service?

2 For counsellors joining a third-sector organisation:

1. Does the organisation match your theoretical approach and ethos? What is their mission
statement? How do they operate?
2. What are the support structures around the organisation - supervision, line manage-
ment, continual professional development? Do they offer specific training to equip you
to work with their client needs?

3 For counsellors looking to establish a service:

1. What areas of my own competence do | need to enhance, either by professional develop-

ment or working with or employing others?
2. Is someone else already doing what | wish my service to do? Can | learn from them?

| Sm M7 SS a Ne ee en a aS
om me |
¢

Learning Activities

Consider allocating resources (time and money) to build partnerships and relationships for
a counselling service. How much time can you spare?
Any counselling that is delivered in the voluntary and third sector needs to be able to
stand alongside other services.To this end counsellors working in this sector should not be
afraid to liaise closely with local and national providers of therapeutic services. Therefore it
is recommended that you match:

e Outcomes — using up-to-date tools

e Standards of practice and core competencies

(Continued)
.
td
414 The Handbook of Counselling Children & Young People

eS 5 ean A a cag ae ee cea ee oe a A

¢
! (Continued)

:e Ethical frameworks l
te Induction, training and other support processes i

i. Find allies in local services that will support your work in all ways and enable a ;
\ sustained service to be delivered. Find a good partnership (or several) that will '
F work to your mutual benefit and so increase the added value to the children and j
| young people. ;
i ii. Match quality assurance processes to those in the statutory sector and, if possible, ,
I exceed them. i
] iii. Join third-sector forums of counselling or those that include counselling - BACP, §
i CYP, Youth Access. Join local voluntary service groups: voluntary action (VA). If 1
i possible, create your own. i
t iv. Join or create local specialist groups for agencies or individuals to work together !
t based around shared themes: for example eating disorders, bullying, etc. !
/ v. Join safeguarding boards, local commissioning groups and NHS clinical commis- i
: sioning groups :
vi. Map out what your service does from aims to outcomes, including a mission state-
1 ment, vision and ethos behind the work '
i vii. Work closely with specialist CAMHS teams, building referral pathways and good \
| working relationships which will support the clinical work and aid with funding 1
Pl applications or approaches to commissioning groups. I
® ®

Online Resources

BACP website: www.bacp.co.uk.

BACP Children and Young People Division.
Counselling MindEd: http://counsellingminded.com — The curriculum includes modules CMD 08:
Counselling in the Community and CMD 11: Counselling and Specialist CAMHS.
Children and Young People’s Improving Access to Psychological Therapies (CYP IAPT): www.
cypiapt.org.
 School and Education Settings
Peter Pearce, Ros Sewell and Karen Cromat

This chapter includes:

e An outline ofthe role of counselling within a school setting

e Asummary of the history of school counselling in the UK
e Details of some aspects of practice for schools counselling
e Acurrent picture of the research on school-based counselling
e An exploration of many of the challenges and benefits of counselling provision within these
settings

Introduction

Counselling in schools is a very accessible and acceptable intervention for young people
and can play a key, pro-active and preventative, early intervention role. It is often a much
smaller step to make contact with a school counsellor than to be referred to a service sep-
arate from the school and can mean that many young people who might otherwise not be
seen, or who might only be referred when problems have become severe and entrenched,
can make use of the service. In addition to this immediate, on-site response, counselling
can also offer support, consultation and training to other staff in the school system.
A range of different school counselling service models currently operate within
the UK which include external agencies delivering the services (for example the local
authority, or a charity) and schools employing their own counsellors. These models of
provision will each impact upon the service that can be provided within the school,
416 The Handbook of Counselling Children & Young People

considerations that need to be taken into account to ensure the clarity of the role and
the lines of responsibility and reporting. Some services have developed along an indi-
vidualised approach with a counsellor ‘in the school but not of the school, and some
have become more system-oriented, seeking to understand and align with the values
and priorities of the school. Similarly some services have developed just to provide
a one-to-one counselling service to students and some have sought to offer a whole
school service which, in addition to one-to-one counselling, might include, a drop-in,
group and family work, peer support, supervision and counselling skills training for
teaching staff and consultation on safeguarding and policy development.
These different models might each have their relative merits - for example, at
the extremes, a lone, independent practitioner might be particularly vulnerable to a
funding crisis, a key ‘stakeholder’ staff member leaving or getting into conflict with a
‘school’s culture. At the other end, an embedded, ‘school-owned’ service might be in
danger of being seen by students as not a safe place to talk (for more details of peer sup-
port initiatives see Chapter 13: ‘Supervisiom).
Whatever structure the counselling service takes in a particular school, it is impor-
tant that the service becomes widely known and what can be offered is understood.
Referrals can come through a variety of sources: from the young person themselves
or a peer, through parents or carers or other family members, via outside agencies
or through a staff member. A majority of referrals are likely, however, to be initiated
because of a staff member’s concern about a young person, maybe because they have
seen them distressed or withdrawn or because they are concerned about the young
person’s behaviour. ‘Could you see Ahmed? He’s very disruptive in class and never
does his homework: Referrals are often co-ordinated through the pastoral care team
with the counsellor expecting the referrer to have spoken to the young person about
their concern and sought consent for the counsellor to at least see them for an initial
meeting. The counsellor’s role is then to offer the opportunity for the young person to
decide for themselves whether a ‘time to talk’ in private is something that they might
like to try out. In this way, within school, a timely response to issues as they arise can
be offered which feels a small step for the young person and seeks to minimise stigma
and pathologising. In this first session, the counsellor needs to be absolutely clear about
the limits of confidentiality, in a way that is clearly understood by the client, and how
any need to break this would be brokered. In this first session the client will be helped
to understand how counselling is different in some ways from other parts of school
life: the client may call the counsellor by their first name rather than ‘Sir’ or ‘Miss’, for
example, quickly signalling how the relationship being offered may differ from that
of other adults in school. One student, recognising the gift in this gesture offered by
the counsellor, replied jokingly, ‘and you can call me Mr Aziz; so the counsellor did,
every time they encountered each other from then on. This first session also provides
an opportunity to acknowledge that attendance at counselling is part of school and
 School and Education Settings 417

boundaries need to be maintained, so for example the client will be expected to turn up
on time for a session and when it is over then return to their next lesson.
Frequent reasons for referral include family problems, managing anger, bereavement,
peer relationship problems and bullying. These may all first come to light because of
changes in the young person's behaviour within school perhaps becoming more dis-
ruptive or more withdrawn. The orientation of the counsellor may to some degree
determine how these issues will be responded to and it is important for the counsellor
to be able to articulate their practice clearly both to the school and to the young person
themselves. However, in order to operate effectively in school, regardless of orientation,
the school counsellor needs to be approachable, adaptable and sensitive to systemic
complexities of this setting. The young person’s behaviour is perhaps best understood
as their way of trying to cope with the problem rather than as the problem itself.

History of School Counselling in the UK

School counselling in the UK underwent a period of rapid development throughout

the 1960s and 1970s, which was later followed by an equally rapid decline in availability
during the 1980s. This rise and fall has been variously attributed to a lack of resources,
the belief that the counselling role should be more part of the school’s pastoral care
team role itself and to the fact that early UK counselling was not embedded sufficiently
well into the culture of the school or adequately monitored (Bor et al., 2002; Baginsky,
2004; Robinson, 1996). The Children Act (1989) brought increased recognition of the
rights of children and young people and with it greater demands on the pastoral care
team role within schools, perhaps becoming instrumental in the reversal of this decline
and renewed interest in school counselling as an accessible, acceptable and appropriate
means of emotional support for young people (Mabey, 1995). Equally, the change in the
devolution of school budgets, under Local Management of Schools (LMS) within the
Education Reform Act (1988), gave head teachers and governing bodies in England,
Northern Ireland and Wales far greater powers to ‘buy in’ appropriate and relevant
services for their individual schools; many commissioned counselling services in both
secondary and primary school settings.
In 2007, the government of Northern Ireland introduced school counselling in all
post-primary schools within the province. In 2008 the Welsh government published its
National Strategy for School-Based Counselling Services (following the recommenda-
tions of the Clwych Inquiry). And by 2009, all secondary schools in Wales had access
to school-based services. In 2013 access to counselling for 11-16-year-olds in Wales
became a statutory responsibility. A commitment to provide school counselling by
2015 was made in Scotland (Public Health Institute of Scotland, 2003). However, there
has been no national overarching programme of implementation across the country.
 418 The Handbook of Counselling Children & Young People

There is now ‘an excellent case for rolling out a new “school counsellor welfare support
role” in all schools, according to a recent report by the influential Institute for Public
Policy Research (Sodha and Margo, 2008).

The Benefits and Challenges

As there are significant differences in the respective professional ‘cultures’ of educa-

tion and therapy it is of importance that roles and expectations are clarified in the
setting up of any school counselling service. For example in one setting it was sug-
gested that the counselling team should put up the counselling list and timetable on
display in the staff room and that the counselling appointments could be read out in
assembly to the whole school as this would help to remind students of their appoint-
ments. At another time there were discussions about the counselling team becoming
class tutors. Whilst these arrangements may be acceptable to some teachers, the con-
fidentiality issues and the dual roles involved would make it impossible to deliver a
confidential counselling service built upon trust. It is important to remember that
the culture, ethics and requirements of a counselling service may not be familiar or
understood by a school who are taking on counselling as an addition to the school
system. Prospective school counsellors, therefore, will need to be able to negotiate
the service to fit within the school context.
This is a challenging setting for counsellors and working with young people in
schools provides its own difficulties. A counsellor can find themselves encountering a
client group who have not elected to have counselling or in some cases even know what
is being offered. Consequently, they can be met by a range of reactions to the referral
which can affect the young person's ability to engage with the counsellor. A counsellor
in this setting would be well advised to have a great deal of experience in establishing
a solid working therapeutic relationship before embarking on working with difficult to
reach clients with complex issues.

ae
Case Study Jason

Jason was referred to the counselling service because he had disengaged from school, had few friends
and was underachieving academically. | was told that his Mum was ‘lovely’ and that she had thought
that counselling might be a good idea when the possibility had been suggested at a parent’s evening. |
was also informed that Jason had reluctantly agreed to see me, and his teachers found him aggressive
and argumentative.
=.
 School and Education Settings 419

eo
When | met Jason our first moments together were awkward. He sat quietly and didn't really want
to engage with me. | said that | realised that he hadn't really wanted to have counselling but had
agreed, which | didn’t think were the same thing. From looking down at the floor this comment
:
seemed to make him look up at me but straight back down again. | struggled to make a connection
with him and he clearly showed me that he didn’t really want to be there. When he first spoke he
used few words and seemed quiet and aggressive in his manner. | said that | wasn’t a teacher and that
he didn’t have to call me ‘Miss’ and that other people had thought he might benefit from some time
to talk. He looked straight at me.

J: What would! wanna talk to you for? Why would |wanna talk to anyone in this fucking school?
| hate it here... | hate school, | don’t wanna fucking talk to no-one. You can report me if you
like.
Th: Report you Jason?
J: | was swearing Miss
Th: Oh that ... that’s okay in here. | think | was listening to the fact that you hate school more
than the swearing. ... |was thinking ... you know it must be a long day if you hate it.
J: Yeah, it is. (laughs)
Th: And every day Jason ... you have to spend a lot of time at school.
J: That's it innit ... that’s just it! Your whole life in a place you hate.
Th: Your whole life in a place you hate.
J: It’s a thing you say innit | hate school. But me, | really do hate school, It’s so boring. ... M... |
was gonna call you Miss then ... what’s your name?
Th: You're bored Jason
Jp Yeah, and all the teachers. ... |hate them as well. ... They hate me too. ... I'm always in trouble.

It was hard to engage Jason and there were moments where | really felt that | managed to feel con-
nected to him, but these moments did not stay. Working with Jason, | always felt as though | needed
to strive to establish and maintain a working relationship. Gradually as our therapeutic relationship
developed, Jason shared more of himself and his struggle to find his place at home in a family of
seven children. Jason said that although he felt loved by his parents he didn’t feel as though they had
the time to listen to him, and | began to realise the place of counselling in his life. He never missed
a session and displayed very difficult behaviour in school if a session had to be moved or cancelled
for school reasons. In the early counselling sessions, Jason would share stories about his school week
and shouted and blamed others for his numerous detentions.

J: It's not fair because | put my hand up to say that | didn’t understand and he kept saying Jason
put your hand down; Jason put your hand down’so I'd had enough right, |just got up and went
to the door. This is ‘im, ‘where are you going?’ This is me, ‘I’m bored; this is ‘im, ‘sit down now!’
just ignored ‘im and walked out.

(Continued)
 420 The Handbook of Counselling Children & Young People

(Continued)

|took my constant struggle to offer consistent acceptance and empathy to supervision and | noticed
that Jason began to process in the sessions.

i: it was jokes today. He said ‘have you done your homework?’! said ‘no’ and he said ‘well what
a surprise Jason’ and we both laughed. Then | said ‘I tried but | couldn't do it He's offered to
help me. I'd like help. It was different today. | usually end up shouting and then he gets cross.
Tak Something was different today Jason, you didn’t end up shouting.
J: Yeah ... yeah ... it’s better really. But it wasn’t just me, he was nicer
Th: He was nicer and you were both different with each other.

As the sessions developed Jason’s focus changed from how fed up he was with school to his struggle
to achieve academically. | wondered whether Jason had learning difficulties and that he was bored
and hated all the teachers because he could not keep up in class. As he began to gain an under-
standing of his experience he identified this for himself and managed to speak to his teacher about
this. Things were put in place to help him to manage school. He was assessed by the educational
psychologist and dyslexia was diagnosed, and consequently he was able to negotiate a shorter time-
table and some help for dyslexia.
Seen
see, bsEs ae,

It would be easy to read this case material and to assume that once the learning diffi-
culties had been acknowledged and help was in place that Jason’s problems were sorted
out. This was not the case — we continued our work together as Jason began to make
sense of his experiencing and to find his own way to manage to come to school and to
participate in school life whilst still hating attending.
School structures require the whereabouts of students to be known so a mechanism
to inform class teachers of a pupil’s absence from class will need to be brokered and
schools may require appointments during some ‘core subjects’ to be avoided altogether.
Part of the complexity of working in a school context is the need to respect the confi-
dentiality of the young person whilst also communicating with the pastoral care team
about the broader picture. Counsellors will therefore need to find a way to liaise with
the pastoral care team and senior management about ongoing work in order to help the
school understand the delicate balance between supporting the young person’s auton-
omy, respecting their confidentiality and acknowledging the needs arising from the
different duty of care held by the school system.
Learning to communicate in a way that is respectful of the school system and negotiat-
ing the differing needs and requirements of the two worlds of counselling and education
becomes an essential competency within this setting. Counsellors can work most effectively
when integrated with the whole pastoral care response of the school and also need to find
a way to enshrine the independence of the service so that students can remain confident of
the difference between their counsellor and other staff in this system.
 School and Education Settings 421

Counsellors will need to consult with their external supervisor and line manager about
the nature of referrals and about the limits of their competence in this setting. They will need
to be familiar with the range of local services for children and young people and understand
how the respective referral processes operate. Reasons for referral on will include seeking
more specialist help for a particular issue, for example PTSD, lack of engagement with the
current service being offered, a specific request by the client or their family and following
the counsellor’s own assessment of their competence with the issues involved.
Counselling in schools requires careful consideration of the potential impact of an
array of additional contextual factors. As has been described, these begin with third-party
referral — it’s most often initially someone else’s concern and they may themselves have
other concerns or none, and this referrer may continue to be involved, often expecting
‘results’ quickly, keen to feedback to the counsellor their views of the issues. There may
also be other ‘stakeholders’ who have a significant influence over whether the young per-
son can continue therapy and the counselling may be taking place in the very setting in
which the issues have arisen. The student and counsellor are highly likely to encounter
each other around the building and see each other interacting with others in the school
system — in fact some of the other ‘characters’ in the person’s narrative may well also be
known to the counsellor. Practical issues may also need careful negotiation, including
rooming for the work, how the young person leaves class to come to counselling, which
classes are acceptable to leave and who in the system needs to be informed that this is
happening. In this setting there is no division between working therapeutically and not,
as staff or students might approach us around the building to connect about a referral
and it is important that the counsellor becomes proficient at managing these one-way
permeable boundaries to ensure that support for the counselling work continues. The
counsellor may also be the only adult who doesnt pick the student up on their uniform,
lateness or behaviour as they move around the school, and this sometimes needs sensitive
brokering both with a staff member seeking additional adult support and with a student
given a window of freedom from the school rules but plunged straight back into them at
the end of the session.

Research

Cooper, M. (2013) School-Based Counselling in UK Secondary Schools:

A Review and Critical Evaluation. Available at: www.iapt.nhs.uk/
silo/files/school-based-counselling-review.pdf

School-based counselling is one of the most prevalent forms of psychological therapy

for young people in the UK, with approximately 70,000-90,000 cases per year. School-
based counselling services in the UK generally offer one-to-one supportive therapy, with
clients typically referred through their pastoral care teachers, and attending for three
422 The Handbook of Counselling Children & Young People

to six sessions. Around two-thirds of young people attending school-based counselling

services are experiencing psychological difficulties at ‘abnormal or ‘borderline’ levels,
with problems that have often been present for a year or more. Clients are typically in
the 13-15-year-old range, white, most commonly female, and presenting with family
problems or, if boys, anger. With respect to effectiveness, non-directive supportive ther-
apy is a NICE-recommended intervention for mild depression; and there is emerging
evidence to suggest that school-based humanistic counselling — a distillation of common
school-based counselling practices in the UK - is effective at reducing psychological
distress and helping young people achieve their personal goals. School-based counsel-
ling is evaluated positively by service users and school staff and is perceived by them as
an effective means of bringing about improvements in students’ mental health and emo-
tional well-being. School staff and service users also perceive school-based counselling
as enhancing young people's capacity to engage with studying and learning. From the
standpoint of a contemporary mental health agenda, the key strengths of school-based
counselling are that it is perceived as a highly accessible service and that it increases the
extent to which all young people have an independent, supportive professional to talk
to about difficulties in their lives. However, there are also several areas for development:
increasing the extent to which practice is evidence-informed, greater use of outcome
monitoring, ensuring equity of access to young people from black and minority ethnic
backgrounds, increasing service user involvement, and enhancing levels of integration
with other mental health provisions. It is hoped that current initiatives in the develop-
ment of competences, e-learning resources and accreditation for counsellors working
with young people will help to achieve this. The conclusions of the review are that
commissioners should give consideration to the utility of school-based mental health
provisions and that school-based counsellors — working with colleagues in the field of
child and adolescent mental health — have the potential to contribute to an increasingly
comprehensive, integrated and ‘young person-centred’ system of mental health care.

British Association for Counselling and Psychotherapy Children

and Young People’s Practice Research Network (CYP PRN)
CYP PRN’s mission is to promote psychological health and emotional well-being
among children and young people in the UK. In supporting high-quality and rigor-
ous research the network seeks to improve the quality and effectiveness of school and
community-based counselling for the benefit of service users and to widen access to
such services by influencing policy-makers and those responsible for the commission-
ing of services. CYP PRN aims to bring together practitioners, researchers and trainers
to engage in research and evaluation in order to develop the evidence base for school
and community-based counselling services for children and young people. This in turn
provides opportunities to improve the effectiveness and acceptability of counselling
interventions and to impact on policy decisions.
 School and Education Settings 423

The Align Trial: A Pragmatic Randomised Controlled Trial of School-

Based Person-Centred Counselling at Secondary Schools in London.
Led by Peter Pearce and Ros Sewell at Metanoia Institute in
collaboration with BACP and Professor Mick Cooper

This study examines the effectiveness of a term (12 weeks) of a standardised school-
based counselling intervention, school-based, person-centred counselling (SBPCC).
The trial builds on the protocols used for three earlier UK RCTs, increasing the control
to nine months and extending follow-up to six and nine months.

Conclusion

Working as a counsellor in a school setting can be both exciting and challenging. It can
feel like work that is at a cutting edge. Current research is showing that counselling can
have a positive impact on young people’s lives which feels like an investment for the
psychological well-being of the future.

Summary

This chapter:

e Has identified some of the complex issues arising in this setting

e Suggests that particular qualities for the counsellor could be useful to develop: diplo-
macy, ability to communicate, enhanced counselling ability and a solid understanding of
ethical considerations, to name but a few
e Identifies that it is essential to ensure supervision with an experienced supervisor who
has knowledge of working in the education system. This is important as a school coun-
sellor can spend a great deal of time in an educative role with staff and careful, ongoing,
negotiation of the counsellor’s role is often required.

Reflective Questions

1 What are the factors to take into account when you as a

counsellor are ascertaining if a client is capable of consent to
counselling? Where can guidance be sought in law?
e Age of client (over 16 generally regarded by law as being competent, unless exceptional
circumstances; and unlikely that a 13-year-old would be deemed competent without
involvement of parent)
424 The Handbook of Counselling Children & Young People

Maturity: understanding of consequences of his or her actions

Suffering mental illness
e Under the influence of drugs including alcohol
e Conditions of Gillick Competence and Age of Legal Capacity (Scotland) Act

2 How can you as a counsellor maintain the trust of clients within

an educational establishment, when you are clearly seen as a
member of staff outside of the counselling room?

e Attention to detail in contracting with client, e.g. reassurance of confidentiality within

usual limits of risk
e Explanation of your role in and around the educational establishment, e.g. may need to
attend staff meetings or be seen talking to other staff in corridors, and confirm that these
conversations are not about the content of the counselling session
e Note that although clients may know others who attend, you will not confirm their
attendance with peers
e Revisit contract regularly, being actively seeking and open to questions
e Besensitive to clients when seeing them around the site — discuss with them in session if
you should acknowledge, smile, say hello, etc.
e Some establishments have policies on confidential discussions. Check to see if yours
does
e Consider your attendance at public functions such as prize-givings, awards evenings,
open days, etc., and if necessary explain to clients in advance that you may be attending

3 In which ways could a counsellor contribute to the institution,

above and beyond their work one-to-one in the counselling room?

e Prepare regular reports for management that identify current trends in the population on
the roll, e.g. bullying and substance misuse.
e Support management in the writing of policies and guidelines for specific and relevant
issues such as safety online and dealing with self-harming behaviours
e Support whole school approaches such as critical incidents (e.g. death of a student or
staff member)
e Provide training for staff in areas such as mental health and well-being
e Provide time in school assemblies or curriculum areas for students, e.g. informing about
the counselling service, stress management during examination periods, etc.
e Attend open days/evenings to inform students, parents and stakeholders about the
counselling service and being able to answer any questions they may have
e Run peer support programmes
 School and Education Settings 425

a" = = = = 2 SS See ee ee
%
i Learning Activities
i
i 1. What are the important factors that you would want to ask about in a referral form to
|
your counselling service? Not all will be appropriate depending on setting, but you may
I
find it helpful to receive information on the following:
1
i e Name and role of referrer
] e Date of referral
] e Name of client
i e Age of client
i e Year group/course studied/faculty
i
e Postal address
|
e Reason for referral
)
e Does the client support the referral?
|
e Parental permission (if appropriate) sought (how and when)
|
i e Can the information on referral be shared with client?
| e Any barriers of access for the client?
i e How urgent is the referral?
J e History (include any other services involved with client and any significant events,
1 e.g. bereavement)
i e Current health (physical and emotional, and including any knowledge of sleep
] habits/drugs/alcohol/food — including energy drinks)
i e Any known details about relationships (peers/staff/family)
|
1 2. Can you devise a document that goes back to the referrer at the end of therapy, that
i updates them on the current situation, without breaking client confidentiality? Include:
|
e Thanks for the referral
i
e Name ofclient
4
|
e ts appropriateness (or otherwise)
| e That therapy is over
i e Client found it helpful (if this is so)
i] e Date
i e Please don't discuss this directly with client
i
i Do:

i
e Discuss this document with your client
|
e Agree what can and can't be said
; ° °
1 e Regard this as a way of promoting appropriate referrals to your service
* *
426 The Handbook of Counselling Children & Young People

Further Reading

BACP. (British Association for Counselling and Psychotherapy) (2011 [2009]) School-Based
Counselling Operating Toolkit. Lutterworth: BACP and Welsh Assembly Government.
McGinnis, S. (2006) Good Practice Guidance for Counselling in Schools. 4th edn. Lutterworth: BACP.
Prever, M. (2010) Counselling and Supporting Children and Young People:APerson-Centred Approach.
London: SAGE.
Smyth, D. (2013) Person-Centred Therapy with Children and Young People. London: SAGE.

Online Resources

BACP website: www.bacp.co.uk/, especially the BACP Children and Young People Division and the
Competences for Working with Children and Young People.
Counselling MindEd: http://counsellingminded.com, especially Modules CMD 0104-6.
 28
Extending Practice: New Horizons
Sue Pattison, Terry Hanley and Olga Pykhtina’

Introduction

This chapter looks at the use of technology in counselling children and young people
and explores the following in relation to the authors’ practice and research:

e Technology and the internet

e Online counselling
e Interactive tabletops

It is difficult to ignore the influence that modern technological developments are hav-
ing upon society and their ‘newness’ is something which can be intimidating. However,
as Douglas Adams reminds us:

Another problem with the net is that it is still technology, and technology, as the com-
puter scientist Bran Ferren memorably defined it, is stuff that doesn’t work yet. We no
longer think ofchairs as technology, wejust think of them as chairs. But there was a time
when we hadn't worked out how many legs chairs should have, how tall they should

' Acknowledgement to Zehra Ersahin for case study material. Zehra is a counselling
psychologist in doctoral training at the University of Manchester whose research interest is in
online youth counselling.
428 The Handbook of Counselling Children & Young People

be, and they would often crash when we tried to use them. Before long, computers will
be as trivial and plentiful as chairs (and a couple of decades or so after that, as sheets of
paper or grains of sand) and we will cease to be aware of the things. (Douglas Adams,
Sunday Times, 29 August 1999)

Despite the awareness of its limitations, the majority of us still embrace technology
and invite it into our homes with the hope that it will enrich our lives. Commonplace
items such as cars, phones, televisions and washing machines have all become reliant
upon computers to aid the tasks that they do. Unfortunately, the fact that the com-
puter within them is still ‘technology’ is unavoidable and with this comes the numerous
flaws and problems associated with it. However, our hunger for such devices remains
unabated by such technicalities, and if computer usage continues to increase on its pre-
sent trajectory it is almost inevitable that computers will become as ‘plentiful as chairs.
However, although the advances (a term that could easily be contested) that we have
already made are significant, the fine-tuning process still has some way to go before the
title of ‘technology’ dissipates and is forgotten. In the meantime we are stuck in a period
of transition and a phase of technological evolution.

Technology and the Internet

The Office of National Statistics reports that 61 per cent of households within the UK
could access the internet from home in 2007 (National Statistics Report, 2009), a figure
likely to have grown significantly since the survey was carried out. This has had an
impact on a range of areas of everyday life. For example, the prevalence of the internet
has inevitably begun to impact upon how people approach health care. For instance,
individuals are reported to commonly use online resources to access information about
health issues of interest before consulting with a professional. Interestingly, surveys
suggest that such practice ‘is not as common as is sometimes reported’ (Baker et al.,
2003: 2400), although this was in 2003 and the use of the internet is a phenomenon
that is clearly on the increase. In addition to this, evidence is mounting which dis-
plays that individuals are increasingly accessing health services online. Probably the
most relevant and striking statistics available are those collected by the Samaritans’
(UK volunteer help and support organisation) email support service. The Samaritans
received and responded to 36,500 emails in the year 2000; this increased to 72,000 dur-
ing 2002 and in 2006 they received 184,000 emails (Samaritans Statistics, 2007). This
phenomenal increase reflects changing attitudes to the internet as a resource, a concept
that is supported by a Market and Opinion Research International (MORI) poll find-
ing (2001) which revealed that 60 per cent of the internet users who were interviewed
would seek help for mental health problems online.
 Extending Practice: New Horizons 429

Technology has impacted substantially upon the world of counselling and psycho-
therapy. It seems important to acknowledge that the world is changing at a fast pace and
today’s technologies, as suggested by Adams (above), will potentially be just part of what
we do in the future. Furthermore, for those who may be a little technology averse, it may
also be a bit frightening to know that it is inescapable and not always within our con-
trol. In this chapter, we discuss how technology is integrated into therapy in a number
of very explicit ways. However, we pay less attention to our softer engagement (that is,
peripheral use of technology, rather than direct work with clients) with such work. For
instance, in Table 28.1 we outline some areas in which technology may creep into our
therapeutic work, both inside (column 1) and outside (column 2) the counselling room.

Table 28.1. Some soft encounters with technology within therapeutic work.

In the counselling room Outside the counselling room

Using a computer to find out helpful You have a website to attract clients
information — ‘let’s consider what the side effects of
Gannabistarets. You use a computer to book appointments and
write your notes
The client shows you pictures on their phone — d
‘here's a picture of my dad...’ You are running late and phone to inform your
client/organisation of this
The client talks about their internet habits — ‘I was
on Facebook last night...’ You have a phone meeting or Skype with a
supervisor
The client talks about problems with cyber
Your manager calculates your effectiveness
bullying — ‘I got this horrible text message
based upon outcome data using a computer
yesterday...’
software package
Using a relaxation audio recording/podcast — ‘how
You complete a training programme online, for
about we use some of the session to practise
example some of the MindEd modules
relaxing?’

You audio record the session — ‘I have an

assignment for a programme I’m studying for,
’
would you mind me recording this session? ...

If we consider the different types of technological involvement noted above, it is

evident how pervasive the use of modern technologies has become.

Online Counselling

If we move to consider more explicit ways in which technology gets integrated into
therapeutic work, we enter a territory that often raises anxieties within a profession
that tends to prize face-to-face communication. We begin to consider the concepts
430 The Handbook of Counselling Children & Young People

of computer-delivered therapy and computer-mediated counselling. The former

reflects computer programmes that have been created to support individuals in
working through specific therapeutic tasks, the most notable being the develop-
ment of computerised cognitive-behavioural therapy programmes, for example,
Beating the Blues for issues around depression or Fear Fighter for issues around
anxiety (Thase and Lang, 2006). The latter concept looks at how individuals can
utilise technology to connect directly with others. Table 28.2 lists some of the
different forms of one-to-one computer mediated counselling that have become
relatively commonplace.

Table 28.2 Common forms of online one-to-one counseling.

Type of mediated counselling Brief explanation

— Electronic mail (email)/Text messages Counselling mediated through email conversations

(asynchronous communication). This might be brief
interchanges or work based upon longer documents.
— Internet relay chat (IRC) Counselling mediated using real-time chat rooms
(synchronous communication).
— Telephone/Voice over internet Counselling using telephone programmes mediated
through the internet.
— Tele/Videoconferencing Counselling in which the counsellor and client can
both see and hear each other on separate computers,
including webinars.
— Avatar Counselling in a space similar to a chat room. In these
spaces those involved will have designed characters to
converse.

Each of these forms brings with it its own nuances and complexities. They prove
attractive to different groups and provide unique strengths. They also each bring
with them their own challenges to overcome (see texts such as Evans (2009) and
Jones and Stokes (2009) for more detailed overviews of such approaches). A common
challenge to such work is the distance between the counsellor and the client, a factor
that seems irreconcilable with therapeutic theory for some (see Pelling and Renard,
2000). Interestingly, however, when considering whether such methods are beneficial
there is an increasing body ofliterature supporting the notion that online therapy can
create strong therapeutic alliances (Hanley and Reynolds, 2009; Hanley et al., 2012)
and result in positive change similar to the effects of face-to-face equivalents (Barak
et al., 2008; Hanley and Reynolds, 2009). This has led the British Association for
Counselling and Psychotherapy to conclude:
 Extending Practice: New Horizons 431

Anecdotal and empirical evidence suggests that it is not only possible to create
deep, emotional relationships online but that, while not replicating them, these can
closely resemble relationships formed in face-to-face therapy. (Anthony and Goss,
2009: 2)

It is important to reflect directly upon how such developments have begun to impact
upon work with young people. Without a doubt this has been an enormous growth
area and online counselling services for this age group have emerged in numerous
countries (see Vossler and Hanley (2010) for a discussion of such services in Europe,
Campbell and Glasheen (2012) in Australia and Pattison et al. (2012) for a discussion
of how such practice might be utilised in Africa). These developments have reflected
a broad shift in how young people appear to be accessing health care provision and
the need to be more responsive to this demand. Table 28.3 outlines some of the rea-
sons put forward by youth online counselling services for their creation.
As is evident, some of the issues noted in Table 28.3 are very practical in nature

Table 28.3 Reasons that online counselling services for young people cite for their
development.

To meet the needs of young people who:

e have concerns, or fears, about approaching a face-to-face counselling service

e live in an area where they are unable to get to a face-to-face counselling service
e have a physical disability which makes it difficult/impossible for them to get to us
e have other commitments/time limits that mean they wouldn't ordinarily seek counselling
e prefer chatting online

To meet service needs by:

e reducing costs
e supporting the creation of easily accessible, thorough session notes
e creating a youth-friendly access point (e.g. see the points above when considering the needs of
young people)
e potentially improving therapeutic relationships with this client group (e.g. by supporting young
people to be more honest with their counsellor and reducing power imbalances present within
adult-young person relationships)

while others intend to directly improve the quality of service offered to those seek-
ing support. There is, however, a counterpoint to such positive views - for instance,
regarding the former, some authors reflect upon the ethical issues or regulation of
such work (Hanley, 2006) and, regarding the latter, some authors note the fear of
young people utilising the internet to perpetuate their own isolation rather than
432 The Handbook of Counselling Children & Young People

connecting with others (Wolak et al., 2003). Caution should therefore be exercised
before moving into such territories as a practitioner.
When considering the quality of online services for young people it is notable that
the research base supporting this work is limited. However, the restricted evidence
base does begin to reflect a similar picture to that of trends in adult counselling. For
instance, young people who have accessed online services report doing so because
they find the internet to be a comfortable and safe space to seek support (Hanley,
2011; King et al., 2006a). Furthermore, strong therapeutic alliances have been
reported (King et al., 2006b; Hanley, 2008, 2011) and positive outcomes observed
(King et al., 2006b). However, it is more sobering to consider that, within the King et
al. study referred to above (2006b; also see Chardon et al., 2011), the alliances proved
weaker and outcomes reduced when compared to telephone equivalents. With such
findings in mind, it is clear that we are just at the beginning of understanding the
impact of new technologies upon therapeutic work with young people. However, we
should be wary of shoving our heads in the sand and ignoring these new develop-
ments. Therefore, we would argue that an open, pluralistic attitude to such work
is adopted that is responsive to the client’s needs when considering issues such as
the psychological approach adopted and the therapeutic medium utilised (also see
Hanley et al., 2013).

Online Counselling with Young People: A Therapist’s Experience

This section reflects upon the experiences of a counsellor working online with young
people as part of an online youth counselling service. The service offers therapeutic
support to young people aged between 12 and 25 and uses synchronous chat, asyn-
chronous emailing, moderated forums and a magazine to support its users. The service
is free at the point of delivery and most users remain anonymous. When young people
sign up to use the service, they create a profile with a user-name, age, an avatar (an
image representing them), and provide the locality through which they access the ser-
vice. Upon registering with the service, users are free to choose the way of support with
which they feel most at ease.

On Becoming an Online Counsellor for Young People

Utilising synchronous chat can pose new challenges within counselling practice. In
face-to-face counselling all therapists work with ambiguity to a certain extent, how-
ever, this can be magnified in an online medium due to the absence of verbal cues and
body language of the client. In particular, the story of the blind men and the elephant
 Extending Practice: New Horizons 433

springs to mind. In this story a group of men (all blind) try to work out what the object
in front of them is by feeling its different parts. They fail, and it is only when they
combine efforts and share experiences that they discover it is an elephant. In much
a similar way, the absence of observational information can prove a major challenge
to therapeutic work and the therapist can feel professionally challenged by the lack of
information. They may contemplate what the young people they work with look like,
what the things they want to reveal are, and what the expressions and feelings are that
they hide. However, relationships with clients change as the therapist becomes more
adept at using his/her other senses.
The following sections present and reflect upon therapeutic work entered into with
young people and the types of issues and challenges encountered. Amended transcripts
collected during a reflexive research project are used to illustrate what online work with
young people might look like.

Utilising Compensatory Techniques

Some of the alternative techniques used to communicate effectively while online
form part of this dialogue, where words are the only tools both therapist and cli-
ent can utilise. With the aim of compensating for the lack of bodily and emotional
presence, the use of emoticons (O©@), acronyms (PAW: parents are watching),
abbreviations (ur: your), capitalisation (SORRY), emotional bracketing (<<<con-
cerned>>>), and words expressing physical contact ({hug}) are used. The following
brief interchange with Locket (avatar pseudonym) might shed some light on the
experience:

Therapist: It seems you have been through HARD times, and still affected by this
loss of {{loved}} one @
Locket: yeah... I still miss him loads @ © © and (...)

Unfortunately, although compensatory techniques can be helpful, communicative

barriers commonly emerge when working using text-based approaches. For instance,
typographical errors and unknown/vague written statements occur quite often.
Therefore, it is the responsibility of the therapist to act upon errors and explicitly seek
clarification where needed:

Therapist: that ounds practical!

Therapist: sounds*
Locket: ©BI5
Therapist: sorry ‘locket, could u explain what ‘BIS’ means
Locket: awww sorry! Back In 5 mins :p
434 The Handbook of Counselling Children & Young People

Beginnings and Endings: Negotiating Goals and Maintaining Time Boundaries

When negotiating therapeutic goals within counselling relationships, particularly
where the work may be brief in nature, it is useful to work towards the articulation of
such a focus in online therapy. Here is an example:

Therapist: im curious ‘lioness’ ... ‘it sounds STUPID’?

Lioness: just seems silly for me to find the situations so stressful and i dont
even get why they do
Therapist: hmm ... what I’m hearing here is if you find the reason behind your
anxiety, it will become more rational and ...?
Lioness: yeah and then I Il be able to try and avoid this or come to terms with
it, but at the moment it seems to have just come over me suddenly and
now i seem to panic more about panicking because Im aware of the
situation happening so it makes it worse!
Therapist: it sounds as if it’s **building UP**! ’'m wondering if then, this could
be our goal to work on for today’s session, then you may feel you are
taking sth from here?
Lioness: yes please
Therapist: kool © shall we identify our goal and start working on it?
Lioness: yes please
Therapist: I would also like to hear your voice ‘lioness’ in this goal. Would you
mind paraphrasing it in terms of your focus or intention maybe?
Lioness: yeah id say that my goal is to work out what it is that makes me anx-
ious in these situations so that i can try to come to terms with this.

Following on from considering the focal points of the sessions it is worth being mind-
ful of maintaining boundaries around the work where possible. In the instance below,
there may be a need to end the session so as not to encroach upon another client’s
time:

Janedoe: its complicated though, we have more to lose, there is more than I told
you and i need to think about it
Janedoe: but thank you
Therapist: no worries at all! I need to close this chat quite soon. but would love
to talk about it MORE ... you want to meet again next week?

Entering the Black Hole: Online Silence

A final issue to raise related to developing online therapeutic work is the issue of
silence — sometimes referred to as the black hole effect. Unlike face-to-face work,
 Extending Practice: New Horizons 435

the power dynamic of the work can operate very differently. A young person may
choose to end the contact at any point of time and this can prove quite a challenge.
Below is an interchange with Feather92 which reflects how this might unfold in
therapeutic work:

Feather92: I would love him to change his mind! But deep down I know he won't!
That's why I always go back to him with the hope that he will change
his mind!
Feather92: _ But he is losing me friends
Therapist: You have a point there ... and yeah I have a feeling about him leaving
me drained ... but J also hear it is either ur ex or ur friends ... where
are ‘u’ in this story ‘Feather92]?
-5 mins passed...-
Therapist: are u there ‘Feather92’?
Feather92: yes
Therapist: sorry, did I upset u?
Feather92: Sorry no! I was just thinking! I dunno..
-Feather92: _ left the chat temporarily-
-3 mins passed...-
-Feather92: entered the chat-
Feather92: Yeah exactly! I think I need to put myself first! I’m sick of not doing
things I want to do to please other people! I’m just scared of upsetting
anyone, I’m upsetting myself!

As is evident in this quote, the session became a little disjointed. It also raised the thera-
pist’s anxieties about what was going on for Feather92. In this instance, the session
ended relatively clearly but this does not always prove to be the case. With this in mind,
and in navigating such silence, supervision has proven invaluable in helping make
sense and learn from such experience.

Therapeutic Use of Technology with Young Children: Digital

Interactive Tabletops and Play Therapy

Although this section looks at digital technology in relation to therapeutic play and
play therapy, it does not explore play therapy as a therapeutic approach (see Chapter 7
for a full account of play therapy). Lack of mental well-being can impact on children’s
behaviour in the classroom and on their learning (Aviles et al., 2006: 20; Wagenaar
et al., 2000: 21) and may lead to offending. Over 90 per cent of young offenders have
had a mental health problem as a child (Mental Health of Children and Adolescents in Great
436 The Handbook of Counselling Children & Young People

Britain in ‘Facing the Future’, 2000). Half of those with mental health problems aged
26 were first identified with a mental health problem by age 15 and nearly 75 per cent
had been so identified by the late teens (Healthy Lives, Brighter Future report, 2009).
Therefore, there is a need for children’s well-being to be promoted as well as the need
for therapeutic interventions.
Technology has become a familiar medium in children’s lives. Video games and vir-
tual reality have been successfully implemented into counselling to treat a range of
anxiety and panic disorders and phobias (Coyle et al., 2005). Yet, despite the rise of
technology in therapies with older children, it is largely missing, or used minimally,
in play therapy with children of primary school age. Mental health interventions may
be of high importance for younger children as it is estimated that 80 per cent of chil-
dren externalising their problems, for example challenging behaviour at the age of five,
develop more serious forms of anti-social behaviour in the future if not provided with
successful interventions (Mental Health of Children and Adolescents in Great Britain
in ‘Facing the Future, 2010).
Interactive tabletops are a new generation of computers that allow direct interaction
with the multi-touch surface and they have been used to promote children’s fantasy
play (Mansor et al., 2009), storytelling (Cao et al., 2010), creativity (Marco et al., 2009),
and interaction (Piper and Hollan, 2006). Although fantasy play, storytelling and inter-
action are some of the concepts play therapy is based on, there is little research on
the use of interactive tabletops in child play therapy. Generally, play therapy remains
embedded in traditional toys, representative objects and other creative materials,
largely provided by the therapist and not rooted in firm evidence. There is no evidence
base regarding the acceptability of digital technology by therapy practitioners or ser-
vice providers, although such evidence is being generated by research carried out by the
authors in partnership with Play Therapy UK and Place2Be.
Toys generally used in the play therapy room are not interactive or computer gener-
ated for a number of reasons. First, there is a belief that technology would interfere
with the therapeutic process when the child focuses more on making the toy work
rather than on expression of role or fantasy play (Carmichael, 2006). Second, frustra-
tion with the toy can lead to the loss of valuable therapy time. Finally, the child can get
absorbed into playing with a toy. If the child does not communicate through words or
play, ‘therapy is just another play session without therapeutic value (Carmichael, 2006:
20). However, there is little empirical evidence to support the above explanation of the
absence of technology in non-directive play therapy. How does the child’s engagement
with traditional static toys differ from their engagement with computerised toys? If
computerised games can support directive therapy (Coyle et al., 2005), what, if any-
thing, can it offer for the non-directive approach and what is the rationale for using
technology, or not?
 Extending Practice: New Horizons 437

The above questions and the children’s increasing requests to bring game con-
soles and other digital devices into the play therapy room (Riedel Bowers, 2011)
motivated a research project to examine the use of digital interactive tabletop tech-
nology in play therapy (Pykhtina et al., 2012). This aimed to understand whether
interactive tabletops could be used in play therapy and how to design applications
for non-directive play therapy. Technology has been introduced into children’s play
for a number of reasons. First, technology is present in adults’ lives and this has
to be reflected in the children’s play through which they make sense of the world
around them. Second, children enjoy interactive toys and find them entertaining.
Mechanical toys can increase children’s interest and engagement in play activities
(Fernaeus et al., 2010). In addition to being just entertaining and engaging, play
with interactive toys has been shown to have therapeutic effects. Interactive toys
support social exchanges and cognitive development of children with socio-rela-
tional disturbances, learning disabilities, and autism and provide opportunities for
emotionally, mentally and psychologically impacted children to fully engage in and
enjoy play (Dautenhahn and Werry, 2004). One of the first designs of robotic stuffed
animals was done to help children with cardiac issues to talk about their problems
and cope with the situation (Bers et al., 1998). The ‘Billow’ system was developed for
children in hospitals, who are quarantined or otherwise isolated, to play in a virtual
audio-visual cloudscape using a malleable, egg-shaped input/output device. This
was intended to address the children’s need for increased human interaction and
social development, mastery and control, comfort and security (Rueb and Wardzale,
1997);
The promotion of social exchanges through digital media has increased especially
with the introduction of interactive tabletops, large horizontal displays that several
users can interact with simultaneously, although in play therapy the interactions are
one-to-one with the child and the therapist. Digital tabletops have been shown to pro-
mote face-to-face interaction (Hatch, 2009) and the benefit of interactive tabletops, for
example in the deaf community, was shown in the study described by Piper and Hollan
(2008), in which the communication between the doctor and the deaf patient was facili-
tated through an interactive tabletop. In addition, games on interactive tabletops have
been revealed to support collaboration between the therapist and children with autistic
spectrum disorder in CBT (Giusti et al., 2011).
The use of tabletops has been extended to promoting children’s creativity through such
play activities as storytelling (Cao et al., 2010) and fantasy play (Mansor et al., 2009).
StoryMat, an application to promote collaboration through storytelling, is a quilt-like
play-mat that records voice and toy movements as a story is being told. Once finished,
the mat selects a similar story to be re-told from an archive, to inspire and allow for
mediated collaboration (Cassell and Ryokai, 2001). StoryTable (Cappelletti et al., 2004),
438 The Handbook of Counselling Children & Young People

is a tabletop application requiring users to select information carried on virtual ladybirds

to create a coherent story to support explicit storytelling. To foster children’s creativity
and collaboration through storytelling, a new system, TellTable (Cao et al., 2010), was
designed to mix tangible objects with created virtual environments. The system allowed
children to incorporate photographs of real-world objects into a story, draw on them and
play back a recorded story. It has been shown to foster creativity, incorporate identity and
support collaboration and interaction.
The attempts to foster children’s fantasy play through the design of interactive
systems on a tabletop (Mansor et al., 2009) have suggested that virtual objects can
stimulate fantasy play, whenever proper interaction design allows children to engage
with them.
Interactive tabletops enable play of a type that would not be available in a traditional
play therapy room (such as playing with floating feathers and snowflakes, lights, fire,
and ice, burning fireballs and frost frames to change picture patterns). These options
support such a therapeutic factor of play as mastery (Schaefer, 1993). They contribute
to the development of the child’s sense of power, control and mastery of their envi-
ronment, especially important for children who live chaotic, disrupted lives (Sallman,
2007). Interactive tabletops afford methods of manipulating objects and images, for
example rotation and scale, that naturally mimic the way one would move a piece of
paper on a tabletop. Scale is intuitive and gives the child new creativity that isn't avail-
able in the traditional play therapy room; in the real world you can't easily make a
picture or object larger.

Figure 28.1 Expressing emotions on the digital tabletop

 Extending Practice: New Horizons 439

The Magic Land software (Pykhtina et al., 2012) is designed to facilitate all aspects
of play therapy in young children. For example, the Water application allows the child
to play with ‘water, making ripples, adding pebbles and various stones, ships and
shells. This was combined with the sounds of rain and thunder and corresponding
visual effects created on the surface of the water to explore the possibility and poten-
tial benefits of bringing music and play therapy together. The child can also add/take
away fish, which are moving around freely but can be affected by the child’s touch.
Water has two therapeutic advantages: it contributes to a sense of happiness and well-
being and is a powerful antidote to the stress of living (Sallman, 2007).

Case Study Dean

Dean, aged five, used the Magic Land interactive tabletop application ‘Rosebush’to express his feel-
ings. He identified himself with a picture of a sad blobby character to depict how he was feeling
when his Dad threw him out of the window. Dean used options to erase a pre-set emotion on a char-
acter’s face and drew a new ‘happy face’:‘l am happy in the warmth by the tree’ He used frost frames
in the ‘Flying’ application to express how he felt about flying when his family were travelling overseas
with a Forces placement: 'This is to make the sky cold. | don't like flying. He chose to play with sounds
of a fireball to describe his father when he was angry and whom he was scared of—‘It sounds like my
Dad ... yes I’m scared of him’
Fantasy play with superheroes was observed to encourage Dean to deal with his fear of fly-
ing. He first created two characters, one that was afraid of flying and the other one a superhero
who was happy with flying. By the end of the play Dean had vanquished the scared figure off the
screen and associated himself with the hero saying: ‘I think I'll put myself down here by the tree
where it’s warm.
It could mean that, through play with the hero, Dean was preparing himself for the flight with his
family. However, could this fear of flying be connected to dealing with Dean’s fear of his father and
the violent episode when he was thrown out of the window? If so, Dean could be working through
deep material that has multiple connections.
2

Summary
S655 SST EEE ESOSA LESTE SSLOES LEE STEELER LE EGET LETITIA EEL,

In this chapter we have looked at the use of computer technology and the internet to support
counselling with children and young people. Several main topics were covered:

e Computers and the internet in counselling practice

e Online counselling with young people
e Interactive tabletops and play therapy with young children
SOS TET EES OLE ELS LE LLL SLES TE
440 The Handbook of Counselling Children & Young People

Reflective Questions

. Reflect upon the case study material provided in the chapter. How would you deal with a
young client who indicated they might harm themselves?
You would follow the ethical framework of your professional body, including taking the
issue urgently to your supervisor if possible and your line manager or safeguarding officer
in the organisation.
. After reading about and perhaps looking at a few interactive tabletop video clips, how
could you see this type of technology helping communication in therapy?
The technology could provide a creative medium to enable the child or young
person to communicate where words may not be possible, or to supplement verbal
communication.
. Reflect upon your own attitudes to and experiences with technology. Would there be any
barriers to you incorporating technology into your counselling work with children and
young people?
This will be a personal reflection - there is no ‘right’ answer.

= ae = = = = = = Ld = aE = ot = =a = = od = == = = bl = = cd a = = &

Learning Activities

1. Check out the online counselling children and young people pathway and learning
resources at: https://www.minded.org.uk/totara/program/view.php?id=68.
2. There are many online counselling resources for children and young people. Use a UK
Google search to locate some of these and check them out.
3. An internet search brings up several video clips on YouTube demonstrating the use of
interactive tabletops in play therapy and sand-tray work. Watch one or two of these
video clips and reflect on whether you would consider using this type of technology in
ee
en
a
Mee
ae
a
a your work with children and young people.
é ®

Further Reading

Pattison, S., Hanley, T, and Sefi, A. (2012) ‘Online counselling for children and young people: Using
technology to address the millennium development goals in Kenya’ in D.B.I. Popoola and O.
Adebowale (eds) Online Guidance and Counselling: Toward Effectively Applying Technology.
Hershey, PA: IGI Global.
 Extending Practice: New Horizons 441

Pykhtina, O., Balaam, M., Wood, G., et al. (2012) ‘Magic Land: The design and evaluation of an
interactive tabletop supporting therapeutic play with children’, in D/S 2012: Proceedings of the
Designing Interactive Systems Conference. Newcastle: ACM Press.
Olga Pykhtina and Sue Pattison’s Interactive Tabletop projects:
http://di.ncl.ac.uk/ilablearn/?page_id=291
http://di.ncl.ac.uk/playtherapy/
http://www.youtube.com/watch?v=Pmm6m8dRwz8s
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 Index

abuse (sexual, physical and emotional) 351-2 attachment

case study 352, 359-62 and endings 233-4
evidence-informed practice 357-8 looked-after children 389-90
general intervention principles 352 and loss 312, 313
labelling 353-4 and supervision 202
legal and policy overview 355-7 theory 13-15
legal process attention-giving 186
in child’s best interests 354-5 autonomy
investigations and referral 147 and beneficence 133
listening 354 and control 164
prerequisites to counselling provision 353 and paternalism 288
Adams, D. 427-8 respect for 281
Adams, J. 310 avoidant/restrictive food intake disorder 370
adolescence see also eating disorders
cognitive-behavioural therapy (CBT) 57 Axline, V. 29, 36, 89, 100, 102, 112, 219
person-centred approach (PCA) 30
relational field of 67 Bachelard, G. 112
self-harm and suicide 332-3 BACP see British Association for Counselling and
adopted children 392-3 Psychotherapy
adult carers Barber, P. and Brownell, P. 74
influence of 158-9 Barrett-Lennard, G.T. 20
primary 14, 15 Beck, A. 50, 188
age et al. 51
ethical approach 279, 287-9 behavioural change 92, 158-9
preparation for therapy 161-2 behavioural experiments 53, 55
psychodynamic approaches 40-1 behavioural studies 11
see also developmental stages behavioural therapy 51
Aman, J. 156 bereavement
American Psychiatric Association (DSM) 369, 370, benefits of therapeutic intervention 310-11
3712 case study 316-17
anger, persistent or unexplained 141 history and background 311-12
anorexia nervosa (AN) 369 process 314-16
see also eating disorders research 312
anxiety, persistent 141 terminology and loss experience 308-10
Aristotle 118 theories and models 312-14
art therapy 115-17 biases, selective attention and memory 53
assessment see preparation for therapy; binge-eating disorder (BED) 370
referrals see also eating disorders
 Index

Bion, W. 36, 40, 87 child development 7-8, 16-17

Bowlby, J. 13, 14, 15, 87, 105, 309, 312, 313 attachment theory 13-15
Bratton, S. et al. 101, 184 case study 17
brief therapy/short-term work 176 cognitive 10-13
gestalt 73-4 critical overview 8-10
person-centred approach (PCA) 30-1 implications for counselling 15-16
play therapy 103-5 see also developmental stages; neurodevelopment
psychodynamic approaches 41-2 child protection see safeguarding and child protection
therapeutic skills 191 ChildLine 322, 332, 336, 337, 341
Bright, G. and Harrison, G. 26 Choose Life 337-8, 343, 345
British Association for Counselling and Cleveland Report 147
Psychotherapy (BACP) Client Change Interview 252
competencies/Competency Framework 185-6, cognitive development 10-13
188, 329, 404 cognitive-behavioural therapy (CBT) 49-50
depression counselling 326 adapting for children 56-60
Ethical Framework 278, 280-1, 287 CAMHS 395-7
child protection 284-5 case studies 58-60, 396-7
legal practice 261-2 eating disorders 374
supervision 207-8 historical development 50
group work 223-4 non-verbal methods 57-8
online counselling 430-1 phases 54-6, 175
Practice-Research Network (CYP PRN) 246, 248, consolidation 55
422-3 psycho-education and relationship-building 54
referrals 131, 133, 147, 148 relapse prevention 56
training skill development 54-5
online (Counselling MindEd) 200, 328, 404 referral and assessment 138
and supervision 199-200 theoretical model 51-3
British Association of Play Therapists (BAPT) 97-8, 101 therapeutic process 53-4
British Sign Language (BSL) 299, 300, 301-2, 303 computer technology 427-8
Bronfenbrenner, U. 9, 163, 321 case study 439
Bryant-Jefferies 173-4 digital interactive tabletops 435-9
Buber, M. 69, 71 internet resources 58, 428-9
bulimia nervosa (BN) 370 see also online counselling
see also eating disorders confidentiality 189, 262
Butler-Sloss, E. 147 challenges to maintaining 285
group work 220
CAMHS see Child and Adolescent Mental Health information-sharing with other professionals 271
Services and privacy 269-70
Castonguay, L. 80, 83 school-based counselling 266, 285
Cattanach, A. 98, 102 young people's concerns 280
charities see third and non-statutory sector see also contracts/contracting; informed consent
Child and Adolescent Mental Health Services congruence 24-5
(CAMHS) 266-7 contracts/contracting 160-1, 271-2, 286-7
and cognitive-behavioural therapy (CBT) 395-6 group work 219-20
CYP IAPT services 267-8, 406-7 Cooper, M. 32, 81, 131, 143, 144, 145, 224, 248, 262,
referral to specialist 133, 143-4, 148 266, 324-5, 421-2
four-tier system 130-1, 386-7, 393-4 and McLeod, J. 81, 122-3
resilience factors and suicide 346 COREY? research tool 411
risk management 394-5 counter-transference 203
self-harm 334, 335-6, 338 transference and 39-40, 90
and third-sector partnership 405 courts: expert witness role 272-3
494 Index

Cowie, H. and Wallace, P. 200 developmental stages cont.

creative approaches 112-13 understanding of endings 232-3
art 115-17 see also age; child development; neurodevelopment
case studies 114, 115-16, 119-20, 121-2 Diagnostic and Statistical Manual (DSM/American
drama 118-20 Psychiatric Association) 369, 370, 371-2
outdoor adventure therapy 120-2 digital interactive tabletops and play therapy 435-9
poetry and song writing 117-18 discourse analysis 252
research issues 122-3 Doring, E. 29
sand tray and storytelling 114-15 drama therapy 118-20
in supervision 204 drama triangle 204-5
in therapeutic practice 113 drop-in centre (case study) 409-10
Crown Prosecution Service (CPS) 356-7 Dryden, W. 171-2
et al. 261, 268, 272, 273 Dunn, J. 16
Croydon Drop In (case study) 409-10
culture/transcultural working 9, 295-6 eating disorders 368
and deafness 300-1 case study 375-7
and development 12, 189 definitions and types 369-72
impact of abuse and trauma 296-9 anorexia nervosa (AN) 369
integrative practice 84-5 avoidant/restrictive food intake disorder 370
psychodynamic approach 41 binge-eating disorder (BED) 370
self-harm 339 bulimia nervosa (BN) 370
other 371-2
Daniels, D. and Jenkins, P. 145, 146, 270, 282, 285 historical and theoretical perspectives 372
Dasen, P. and Mishra, R.C. 9, 12 key models for engagement and intervention
data protection 272 S73—5
deafness 299-303 cognitive-behavioural therapy (CBT) 374
awareness and good practice 302-3 family-based treatment (FBT) 373-4
communication methods and preparation 301-2 other 375
cultural and educational backgrounds 300-1 ecosystem theory 9, 163
terminology 299 educational settings see school-based counselling
death, concept of 314-15 Ellis, A. 50
Department for Education (DfE/DfES) 131, 305, 355 ‘embedding’ and ‘disembedding’ 66-7
Department of Health (DoH/DH) 112, 266, 287, 288, emotional abuse see abuse (sexual, physical and
346-7 emotional)
depression 320 emotions
case study 329-30 indications for therapy and presenting problems
counselling interventions 324-7 140-2
counsellor’s practice 327-9 skills development 55
history and background 321 of supervisee 202-3
level and symptoms 321-2 of therapist 203
prevalence 322 empathy 26-7
risk factors 322-3 endings 229-30
DesLauriers, A.M. and Carlson, C.F. 390 approaches to 238-40
Devaney, J. et al. 321, 323, 325-6, 333, 340, 342, 344, activities and gifts 239-40
345, 348 preparing child 239
developmental stages 188-9 preparing parents 238-9
cultural differences 12, 189 timing 238
integrative practice 85 avoiding 237-8
issues in supervision 201-2 case studies 91-2, 231
understanding of death 314-15 considerations 232-4
 Index 495

endings cont. Fraley, R.C. and Shaver, P.R. 312

attachment 233-4 Frankl, V. 303, 305
development 232-3 Freud, A. 36, 41, 100, 286
outcomes of 230-2 Freud, S. 10-11, 35-6
consolidation of therapy process 231
preparedness for progress 232 games consoles 436-7
resolution of therapeutic relationship 231 Gardener, H. 162
types of 234-7 Gaskin case 263, 272
managed care 237 Gaston, L. et al. 176
natural 234-5 Geldard, K. and Geldard, D. 25, 26, 30, 48, 82-3, 114,
premature 235-6 115, 190-1, 287, 321
environment Gerhardt, S. 388
child’s 139-40 gestalt 64
therapeutic 156 background and history 68-9
ethics 277-8 brief therapy 73-4
approaches 279-81 case studies 70, 71, 74-5
BACP Framework see under British Association for field theory and evolution of self 65
Counselling and Psychotherapy (BACP) relational field 65-6
case study 289 of adolescence 67
legal practice 261-2 of childhood 66-7
practice and codes 278-9 research 74
research 287-9 shame-support dynamic 67-8
rights-based approach 281-4 theory-practice relationship 70-3
rule-based and outcome approaches 284-5 client’s sense of self 72
see also autonomy; confidentiality; contracts/ completing the gestalt 72-3
contracting person of therapist 70-1
ethnicity see culture/transcultural working therapeutic relationship
evaluation of counselling establishing 71
evidence-based practice and practice-based and unfinished situations 66
evidence 246 gifts, ending of therapy 239-40
experience for clients and therapists 244-5 Gillick case/competence 263, 266, 269, 270, 327, 339
group work 221 Gillon, E. 21-2, 138
impact on outcomes 245 Gilmore, S. 82, 83, 84
outcome and process feedback 247-8 goals
qualitative and quantitative methods 252-3 mapping 156-7
research-practice relationship 245-6 online counselling 434
tools 248, 249-51 in therapeutic alliance 171-2
Everall, R. and Paulson, B. 173-4 Goodman, P. 65, 66, 68, 69
evidence-based practice see research and evidence- Greig, A. et al. 288-9
based practice grief see bereavement
expert witness role 272-3 group work 212-15
abuse (sexual, physical and emotional) 356, 362-3
family-based treatment (FBT) context 221
eating disorders 373-4 contracting and maintenance models 219-20
see also systemic approach as economic intervention 215
Favazza, A.R. 394 example 221-3
Feltham, C. 176 facilitator attributes 216-17
field theory see under gestalt history and background 218-19
Fonagy, P. and Target, M. 13-14, 16 life cycle of group dynamic 217-18
foster children see looked-after children outcome evaluation methods 221
 Index

group work cont. Joiner, T.E. et al. 346

research 223-4 Jones, A. 199
selecting participants for 215-16 Joyce, A. et al. 230-1, 233

Hawton, K. et al. 323, 332-3, 334, 340, 341-2, 343, Karpman, S.B. 204-5
344, 345-6, 347 Kirschenbaum, H. and Henderson, V.L. 19, 20
health and social care services 383-4 Klein, M. 11, 36, 100
adopted children 392-3
foster children see looked-after children labelling 353-4
practice and policy development 384-7 Lambert, M.J. and Barley, D.E. 184-5
see also Child and Adolescent Mental Health law
Services (CAMHS) case study 273-4
Hollanders, H. 81-2, 83 confidentiality
Holmes, J. 175-6 and information-sharing 271
hopelessness, persistent feelings of 141 and privacy 269-70
Horton, I. 175 court appearances 272-3
Houston, G. 197, 198 defining 259-60
Hughes, D. 389 ethical dimensions of practice 261-2
humanistic approach 153-4 and policy
research 262
Improving Access to Psychological Therapies (IAPT) service provision 265-8
267-8, 406-7 specific to counselling children and young
indications for therapy 140-3 people 262-4, 268-9
individual variation 162-3 see also under abuse (sexual, physical and
information-sharing 271 emotional)
informed consent 288-9 pre-trial therapy 268, 273
Gillick competence 327, 339 record-keeping and data protection 272
Inskipp, F. and Proctor, B. 207-8 rights-based model 260-1, 269
Institute for Public Policy Research 418 supervision 203-4
integrative practice 80, 81 see also contracts/contracting; safeguarding and
case study 85-92 child protection
behavioural change 92 Lazarus, A. 146
ending 91-2 learning disabilities 303-5
formulation 87-8 learning styles 162-3
relationship-building 89 Lee, R.G. 68
relationship-deepening 90-1 et al. 83
supervision 89-90 LeSurf, A. and Lynch, G. 280
and developmental perspective 85 Lewin, K. 218
history and background 81-3 life story work 390-1
practice-led core principles 83-4 listening 153, 186, 187, 354
practice-led model 84 looked-after children 387-92
transcultural challenges 84-5 attachment-focused parenting 389
intelligence and learning styles 162-3 case studies 389-90, 391-2
internet common experiences 387-8
resources 58, 428-9 life story work 390-1
see also online counselling referrals 147-8
isolation/withdrawal 142 therapeutic work 388-9
Theraplay 390
Jenkins, P. 260, 263, 272, 273, 279, Lorenz, K. 13
282, 284 loss 141
Daniels, D. and 145, 146, 270, 282, 285 attachment and 312, 313
and Palmer, J. 285 see also bereavement
 Index 497

McConville, M. 65, 66-7 outcomes

Magic Land software 438-9 preparation for therapy and 166
Malchiodi 112, 113 and rule-based approaches 284-5
mandalas 116-17 see also under endings; evaluation of counselling
mapping see under preparation for therapy outdoor adventure therapy 120-2
Martin, p.B. 303, 305
Mearns, D. and Thorne, B. 21, 22, 23, 24-5, 27, 31, PACE model 389
174-5 parents
Mental Health Foundation 322 initiating endings 235-6
mental health services 266-8 preparing for endings 238-9
see also Child and Adolescent Mental Health rights 269
Services (CAMHS) Parkes, C.M. 309, 310, 312, 313
metaphors 57 peer mentoring services 200
play therapy 90, 91, 98 Perls, FS. 66, 70
middle stage of counselling process 174-6 et al. 67, 68-9
Midgley, N. and Kennedy, E. 44 person-centred approach (PCA)
Mikulincer, M. et al. 14 and assessment 138-9, 154
MIND 333, 334, 335, 337, 340, 343 case study 31
monitoring client process and progress 177-8 core conditions 23-7
Moore et al. 232, 233, 236, 237, 238 congruence 24-5
multi-disciplinary approach 385-6 empathy 26-7
unconditional positive regard 25-6
National Association for Poetry Therapy 117 group work 219
National Institute for Health and Clinical Excellence history and background 19-23
(NICE) process
CBT 395, 396 middle phase 174-5
depression 321-2, 323, 324, 325, 326 seven stages 27
self-harm and suicide 333, 338, 339, 345, 395 referrals 138-9
National Society for the Prevention of Cruelty to research 31-2
Children (NSPCC) 327, 333, 335, 337, 339 self and self-concept 22-3
negative automatic thoughts 52 short-term work 30-1
Nelson-Jones, R. 175 theoretical underpinnings 20-2
neurodevelopment therapeutic realtionship and approach 28-30
abuse and trauma related to difference 298-9 physical abuse see abuse (sexual, physical and
plasticity 9, 10 emotional)
play therapy 100-1 Piaget, J. 11-12, 161, 232, 314
non-statutory sector see third and non-statutory Place2Be 410
sector play therapy 29
non-verbal methods 57-8 case studies 89, 105-7
Northern Ireland Commissioner for Children and definition and approaches 97-9
Young People (NICCY) 336 digital interactive tabletops 435-9
gestalt 72-3
Oaklander, V. 68, 69, 70, 72-3, 74, 116, 117, 118 history, background and context 100-2
observing 38-9, 186 in schools and brief therapy 103-5
O'Connor, R.C. et al. 335, 336, 337 theory-practice relationship 102-3
online counselling 429-32 see also creative approaches
challenges 432-3 poetry and song writing 117-18
compensatory techniques 433 policy see under law
goals and time-boundaries 434 power issues, supervision 204-5
silence 434-5 Practice-Research Network (CYP PRN) 246, 248,
online training (Counselling MindEd) 200, 422-3
328, 404 Pratt, J. 218
 Index

pre-trial therapy 268, 273 referrals 129-30

preparation for therapy and assessment 137-9
case studies 162, 164-5 cognitive-behavioural therapy
contemporary developments 154-5 (CBT) 138
humanistic approach 153-4 person-centred 138-9, 154
listening as critical task 153 psychodynamic 138
mapping 155-61 systemic therapy 137-8
context 157-9 CAMHS 130-1, 133, 143-4, 148
contracting 160-1 case studies 134-6, 140, 148-9
personal problems and goals 156-7 child’s environment 139-40
reviewing ‘assessment meta-map’ 160 counselling settings 144-6
risk identification and assessment 157 see also specific settings
standardised measures 159-60 forms and assessment 132-6
therapist and environment 156 good practice issues 133-4, 146-8
theoretical underpinning 161-7 abuse and investigations 147
age and stage 161-2 looked-after children 147-8
context 163-4 referral to other agency 146-7
individual variation 162-3 indications for therapy and presenting problems
outcomes 166 140-3
schema development 165 initial meeting 136-7
presenting problems, indications for therapy and policy background and history 130-1
140-3 third-party 421
primary caregiver 14, 15 reflection, PCA 28
private practice 146 Reid, H. and Westergaard, J. 28
projective identification 203 relapse prevention, CBT 56
projective play 99 relational field see under gestalt
psycho-education phase, CBT 54 relationships
psychodynamic/psychoanalytical approaches significant 9, 16
10-11, 20 see also attachment; therapeutic alliance/
assessment at referral 138 relationship
background and history 35-7 report writing 272-3
case study 37, 42-3 research and evidence-based practice
core features and development 45-6 abuse interventions 357-8
middle phase 175-6 bereavement counselling 312
practitioner skills, attitudes and beliefs 38-40 creative approaches 122-3
research 43-5 ethics 287-9
short-term work 41-2 gestalt approach 74
use across age and ability range 40-1 group work 223-4
puppets 58 law and policy 262
puzzle grid assessment tool 139-40 person-centred approach (PCA) 31-2
psychodynamic approaches 43-5
qualitative and quantitative evaluation school-based counselling 421-3
methods 252-3 supervision 207-8
third and non-statutory sector 410-12
randomised controlled trials (RCTs) 252-3, 312 see also evaluation of counselling
record-keeping responding 186
and data protection 272 reviewing
depression counselling 328 ‘assessment meta-map’ 160
Reeves, A. client process and progress 177-8
and Howdin, J. 327, 334, 335, 338, 339, 340 Richardson, C. 335
and Seber, P. 345, 346 rights-based approach 260-1, 269, 281-4
 Index 499

risk separation anxiety 313

identification and assessment 157 sexual abuse see abuse (sexual, physical and emotional)
management 394-5 shame-support dynamic 67-8
risk-taking 120-2 Shedler, J. 44
Rogers, C. and Farson, R. 187 short-term work see brief therapy/short-term work
Rogers, C.R. 19-21, 22-3, 25, 27, 28, 100, 138, 154, Silverman, P. and Klass, D. 309
171, 173, 188, 201 Simkin, J. 69
group work 214, 217, 219 skill development
role-play 99 CBT 54-5
Rowling, J.K. 316 see also therapeutic skills
Royal College of Paediatrics and Child Health 147-8 Skinner, B.F. 11
Royal College of Psychiatrists Social Care Insitute for Excellence (SCIE) 323, 328,
depression 321, 323, 325 334, 335, 343
self-harm and suicide 337, 338, 342-3, 395 Socratic dialogues 53, 55, 57
song writing and poetry 117-18
sadness, persistent feelings of 141 Spong, S. et al. 131, 144, 145, 267, 408
safeguarding and child protection 270, 355-7 Stallard, P. 53-4
BACP 284-5 statutory agency settings 145
supervision 356 see also Child and Adolescent Mental Health
see also abuse (sexual, physical and emotional) Services (CAMHS)
sand tray 114-15 Stern, D. 38, 65, 87, 90
‘scaffolding’ 12-13 Stern, D.N. et al. 82
schemas 51, 52 storytelling 102
for therapy 165 life story work 390-1
school-based counselling 415-17 and sand tray 114-15
benefits and challenges 418-21 technology 437-8
case studies 289, 418-20 suicide 332-3, 340
confidentiality 266, 285 case study: Terry 348-9
depression 324-5 interventions 343-8
history 417-18 prevalence 341
law and policy 265-6 risk factors 341-3
play therapy and brief therapy 103-5 see also self-harm
referrals 145 supervision 196-7
research 421-3 case studies 89-90, 205-7
‘schoolism’ 81 child protection issues 356
Scott, M.J. and Stradling, S.G. 296-7 depression counselling 327
selective attention and memory biases 53 history and background 199-200
self power issues 204-5
development 65, 72 research 207-8
and self-concept 22-3 self-harm counselling 340
self-care 71, 327, 340 symbolism and creativity 204
self-harm 332-3 theoretical underpinning 200-4
and counselling 333-5 attachment issues 202
indicators 337-8 developmental issues 201-2
interventions 338-40 legal issues 203-4
prevalence 335-6 supervisee’s feelings 202-3
risk factors 336-7 systemic thinking 200-1
see also suicide triple function of 197-9
‘self-talk 12, 52 plumber 198
semi-structured interviews and analysis 252 poet 198
sensory play 99 policeman 197-8
500 Index

symbolic play 204 Thompson, W. 143

systemic approach time-limited work see brief therapy/short-term work
referral and assessment 137-8 timing of endings 238
supervision 200-1 toys 104
see also family-based treatment (FBT) interactive 437
puppets 58
Targeting Mental Health Support (TaMHS) 411 training see under British Association for Counselling
therapeutic alliance/relationship 170, 171-4 and Psychotherapy (BACP)
building 54, 71, 89 transcultural working see culture/transcultural working
case study 178-80 transference and counter-transference 39-40, 90
counselling process and middle stage 174-6 Trower, P. et al. 175
deepening 89, 90-1
monitoring client process and progress 177-8 unconditional positive regard (UPR) 25-6
resolution of 231 unfinished situations 66
and unfinished situations 66 UNICEF 281, 283, 304
therapeutic skills 183-5 United Nations Convention on the Rights of the
brief therapy 191 Child (UNCRC) 261, 281, 283, 333, 384
case study 191-3
defining 185-8 voluntary services see third and non-statutory sector
specific to children and young people 188-90 volunteers 408-9
therapists Vygotsky, L.S. 11, 12-13, 15, 166
feelings of 203
gestalt 70-1 Walker, S. 189
host role 156 West, J. 190
initiating endings 236 Winnicott, D. 36, 87, 88
online counselling experience 432-5 Winter, D. et al. 326, 341, 347-8
personal qualities 190-1 withdrawal/isolation 142
psychodynamic 38-40 World Health Organization (WHO)
self-care 71, 327, 340 health and care system 385
Theraplay 390 suicide 321, 323, 340, 341
third and non-statutory sector
history and background 401-3 Yalom, I.D. 214-15
organisational case study 409-10 Young Minds and Cello 394-5
referrals 145-6 Young Persons Clinical Outcomes in Routine
research 410-12 Evaluation (YP CORE) 178, 253
service provision 407-9 Youth Justice Board Mental Health Report 131
and statutory partnerships 404-7
theoretical underpinnings 403-4 zone of proximal development 166
ag0HBAQMAL TEAW
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COLLEGE
LEARNER ZONE
‘This is a timely and useful resource. With an impressive list of authors who are contemporary subject
specialists, the text covers a comprehensive range of topics that will interest many stakeholders.’
Karen Cromarty, Senior Lead Advisor, BACP

‘This book has it all, and is a “must have” for all practitioners and trainees working therapeutically with
children and young people.’
Phil Goss, Senior Lecturer in Counselling and Psychotherapy, UCLAN

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