Counselling Children and Young People in Private Practice

A Practical Guide

Rebecca Kirkbride

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781782202615
• eBook ISBN: 9780429912320
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

With statutory CAMHS services often heavily oversubscribed, and school and college services mainly offering brief therapeutic interventions, parents are increasingly turning to private practitioners for therapy for their children when they need expert emotional or psychological support. Working privately with children and families can be a rewarding experience for counsellors and psychotherapists but it can also be fraught with concerns for both practitioners and families alike. These concerns can seem so daunting that therapists with clinical experience of therapy with children continue to limit themselves to working only in education or statutory settings. This book offers comprehensive guidance to both experienced and novice counsellors to assist them in the process of setting up or adapting their private practice to include children and young people. It coherently and systematically addresses the obstacles which stand in the way of practitioners offering this important service effectively and ethically. The book is divided into four parts and uses case material to bring to life the areas covered by each chapter.

Part I
Private Practice with Children and Young People

CHAPTER ONE
Referral and assessment

In all therapeutic work, the referral and assessment stages can play a vital part in determining the shape and success of the therapy to follow. In work with children and young people in private practice this can be a complex aspect of the work which demands close attention and skill from the practitioner. Amongst other things, therapists must think about establishing a therapeutic relationship which includes parents or carers, assess and then consider the impact on the therapy of the developmental stage a child or young person has reached, as well as come to a decision regarding a client’s capacity to consent to a confidential therapeutic relationship.

Throughout this chapter case vignettes will be used in order to give practical examples of how a practitioner might approach referral and assessment in their private practice.

Initial referral

Case material: Heather and Conor—Part One

Heather is a counsellor of children and young people in private practice. She receives a voicemail from Yasmin who is seeking counselling for her eleven-year-old son, Conor. In her message, Yasmin says that she found Heather’s details in an online therapy directory. Yasmin expresses concerns about Conor’s adjustment after her recent separation from his father. He appears anxious about going to school and is no longer enjoying his out of school activities such as football club and karate. She asks Heather to please call her to arrange an initial appointment.

Where therapy with children and young people in private practice differs significantly from work with adults is in the necessity for practitioners to have a relationship not only with the client but also with a third party, generally a parent or carer. This unique element of the work is one which will be referred to frequently throughout the chapters of this book as it represents a fundamental consideration in this area. Managing the complexity of a relationship with both the client and their parents can raise anxiety for practitioners, which is why close attention will be paid to it within these pages. From the first contact with a parent seeking therapy for their child, no matter what the child’s age, the therapist needs to begin to build a rapport and relationship with the parent, enabling them to feel comfortable about bringing their child for counselling. Parents and carers will be wanting to get a sense of the therapist’s warmth and approachability just as do prospective clients in adult practice. Any conversations or contact early on in the process between therapist and referrer provide an opportunity for parents to be given a sense of the potential for understanding and the positive outcome to be gained from therapy for their child. The therapist must, however, remain mindful that the adult here is not the client and that in the future, if the counselling goes ahead, they will be building a confidential therapeutic relationship with the child which the parent(s) will to some extent be excluded from. If this complex dynamic is not understood at this stage it can become difficult further on to offer the client a clear sense that the therapist is there for their benefit and is not simply another “parent-like” adult following an agenda based on the parents’ wishes, with no consideration of the client’s needs. The demand on the practitioner here is to skilfully manage to create an alliance with the referring parent but also to create and maintain boundaries which will allow for the provision of a neutral therapeutic space when work with the client begins.

Whichever terms are used to describe the referral and assessment phase of the therapeutic relationship; initial consultation, assessment, preliminary interview or history taking, many of the elements of the process will be similar. In, “Why assess”, Tantam (1995) outlines the goals of the “first psychotherapeutic interview”. These include; “establishing rapport with the patient”, “obtaining pertinent information”, “giving information”, “enabling the patient to feel understood and giving hope”, “giving the patient a taste of the treatment” and “making practical arrangements for therapy”. “Why assess” was written with individual psychotherapy with adults in mind but these goals are clearly relevant to work with children and young people and their parents or families. However when assessing for work with the latter we need to think about the process slightly differently and take some other important factors into account.

The way the referral and assessment stages are managed with parents will depend to a large extent upon the age and developmental stage or phase that their child has reached. Throughout this book we will be examining how developmental stages will influence the form that therapy takes and this is of particular importance at assessment. Clearly the developmental needs and dependencies of a five-year-old are considerably more parent-centred than those of an eleven or seventeen-year-old. Parents are generally the driving force behind the therapy of younger children whereas post-puberty and during the individuation processes of adolescence, children may have a far greater sense of their own autonomy regarding their issues and some sense of the need for assistance in working with these. As Anna Freud (1965) writes;

Some of the most lively controversies concerning the specificity of child analysis are related to the question whether and how far parents should be included in the therapeutic process. Although this is overtly a technical point, the issue at stake is a theoretical one, namely, the decision whether and from which point onward a child should cease to be considered as a product of and dependent on his family and should be given the status of a separate entity, a psychic structure in its own right.

(A. Freud, 1965, p. 43)

Anna Freud goes on later in the same chapter to suggest that practitioners take note of not just a patient’s chronological age but also of what use he makes of his parents in order to assess his state of “dependency or independence”. She suggests; “… it is essential for the analyst to realize in which of the vital respects the child leans on the parents and how far he has outgrown them” (A. Freud, 1965, p. 46).

The following table illustrates the modes of relating to parents that Anna Freud suggests demonstrate a child or young person’s state of dependency or independence.

Table 1.1. A. Freud—Developmental stages of dependency.

Uses that a child makes consecutively of his/her parents (A. Freud, 1965)	How this might present at referral/ assessment
For narcissistic unity with a motherly figure, at the age when no distinction is made between self and environment.	A child or young person who struggles in sustaining a separate sense of themselves in relation to the parent or others.
For leaning on their capacity to understand and manipulate external conditions so that body needs and drive derivatives can be satisfied.	A child or young person unsure of how they can exist without the help and support of a parent to keep them alive and functioning. No sense at this point of their own potential or resources in this respect. They may understand that they are not their parents at this stage but not that they could survive without them.
As figures in the external world to whom initially narcissistic libido can be attached and where it can be converted into object libido.	A child or young person who is developing an ongoing sense of themselves through their relationships and connections to others. Parents in this respect are connected with in order to be able to explore aspects of self and other relationships.
To act as limiting agents to drive satisfaction, thereby initiating the child's own mastery of the id.	A child or young person who is in need of externally provided boundaries to help them manage themselves and to develop a stable and functioning ego.
To provide the patterns for identification which are needed for building up an independent structure.	A child or young person who has a fairly well established sense of themselves internally but still requires external adult identifications to help their transition to independence from their parents.

It can be helpful when thinking about working with young clients to assess what stage they have reached in this respect and to consider whether a client is able to think about themselves and their experiences separately from how their parents think about them. It was twenty years after Anna Freud was writing about a child’s right to be considered a separate entity that the legislative processes in the UK and elsewhere began to consider such concepts within the law regarding children’s’ rights, culminating in the establishment of “Gillick” competency.

Gillick competency

The “Gillick” case of 1985 was fundamental in the UK to helping practitioners in thinking about the parents’ role in their child’s therapy. This case gave rise to the term “Gillick Competency” and preceded the Children Act of 1989 which gave children further rights separate to their families’ or the state’s wishes for them. Victoria Gillick brought her case to the House of Lords when her local health authority failed to offer her assurance that none of her five daughters would be offered contraceptive advice or services prior to the age of sixteen without her permission. Her action followed the publication of a local authority information pamphlet suggesting that the prescribing of contraceptives to minors under sixteen be at the doctor’s discretion rather than the parents’. When Gillick’s case was rejected by the House of Lords the ruling meant that children had been acknowledged by law as independent of their parents. The Gillick case then gave rise to the Gillick test. In discussing the Gillick case, Daniels and Jenkins (2010) quote Lord Scarman as saying:

… the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him to understand fully what is proposed. (Gillick v. West Norfolk AHA, 1986, at 423)

(Daniels & Jenkins, 2010, p. 19)

In private practice, where the referral is generally made by the parents or legal carers of a child or young person, there is no need to refer to Gillick in terms of whether treatment can be offered as the referral itself implies parental consent. However, in terms of how an agenda for therapy is set, contracts made regarding confidentiality and record keeping, and how we involve parents in their child’s therapy, Gillick and the general concept of capacity to give consent do have a relevance.

The Gillick ruling made it clear that anyone offering treatment to a child or young person must consider them able to make their own choices, without the knowledge or consent of their parents, regarding this treatment if they have reached a point of sufficient intellectual and emotional capability to do so. The practitioner is required to make this judgement and must feel confident in doing so.

The principles of Gillick have been adopted elsewhere around the world including in Australia, New Zealand, and Canada. In the US the law is more complex on the rights of minors to access confidential medical treatment and can vary from state to state. On the whole, most states have laws which recommend that children have access to confidential medical treatment from around the age of fourteen but that right is limited if the child is considered to be at significant risk of harm. There is a federal guideline within the “Patient Privacy Rule” which took effect in 2003 that states that parents should have access to “information about the health and well-being of their children” but this also states that “disclosure of health information about a minor child to a parent should be governed by state or other applicable laws” (Weisleder, 2004, p. 147). We will return to Gillick competency and the law around counselling children in Chapter Five.

Developmental models

There are some useful developmental models to consider when thinking about the assessment of children and young people for therapy. Jean Piaget, a Swiss psychologist, studied and wrote extensively throughout the 1920–1970s on the subject of children’s’ cognitive development. Piaget recognised that children’s ability to think and make sense of their world went through different stages as they grew up. He saw children’s thinking as going through four major developments as outlined below:

Table 1.2. Piaget’s stages of cognitive development (1964).

Age	Developmental stage
Birth to two years	Sensorimotor stage—infants and babies experience the world through sense and action.
Two to six years	Preoperational stage—young children begin to represent and understand their experiences through words and images.
Seven to eleven years	Concrete operational stage—children are able to think logically about concrete happenings and make analogies between them.
Twelve years onwards	Formal operational stage—adolescents and young adults are able to consider hypothetical situations and process abstract, non-concrete, thoughts.

Considering clients at assessment in relation to these stages can help practitioners not only decide how to work therapeutically but also in understanding how able a particular child is to consent to and actively take part in decisions about their own therapy. Once a child has reached the formal operations stage they are more likely to be able to consider fully the implications of confidentiality in their counselling and be able to give informed consent in this respect.

Bowlby and attachment theory

Attachment theory, developed by John Bowlby (1973) during the 1940s and 1950s is also appropriate for use by practitioners when assessing children and young people for counselling. Bowlby was a psychiatrist and psychoanalyst who used ethological studies as the basis for understanding human development and relationships. He was particularly interested in the impact that any separation from their main caregiver had on young children’s emotional and psychological development.

As Bowlby (1973) continued to explore the nature of children’s attachments, his discoveries led him to conclude that in order to develop a secure attachment, children required a caregiver who was both psychologically and physically present as well as emotionally available. The effects of being raised by an emotionally or psychologically unavailable parent could be just as significant as temporary or permanent physical separation from the caregiver. Attachment theory suggests that the early experiences children have of their caregiver’s ability to respond appropriately to their needs leads to the development of an “internal working model” (Ainsworth, Blehar, Waters & Wall, 1978), which then becomes a fundamental factor for the child, determining to a great extent how they will experience themselves and their relationships as they grow older. Early attachment experiences in this way are important in the building of a mental representation of the self, others, and the relationship between self and other. The child quickly begins to develop a sense of their own worthiness and acceptability to the other, as well as how reliably others and the world around them will meet their emotional and physical needs. Their behaviour is adaptive according to these discoveries, becoming the basis of strategies intended to help the child maintain proximity to their attachment figure and secure base. An example of this is when a child experiences their emotions as causing their parent to move away from them, and therefore begins to try to suppress or hide their true feelings from the parent in an attempt to prevent the feared abandonment.

While working with Bowlby on experiments aimed at observing and understanding children’s attachment behaviour and patterns, Mary Ainsworth developed the “strange situation” test (Ainsworth, Blehar, Waters & Wall, 1978) for classifying children’s attachment patterns at an early age. This test consisted of creating a situation in which mother and child are together, then a stranger enters the room, mother leaves and then returns after a short while. The reaction of the child to both the stranger, the separation from mother and her return were all monitored and then classified according to the attachment “pattern” they best fitted. Bowlby (1973) proposed that children were either securely or insecurely attached to their parent figure and that this attachment was an indicator of their capacity to develop and cope with separation and loss as they grew older and became adult. The behaviour of the child in this test indicated the adaptations they had made to their proximity seeking behaviour in order to maintain some sense of connection to their caregiver. Ainsworth took the results of the test and categorised them according to the behaviours exhibited as shown in table 1.3 below:

Table 1.3. Attachment patterns.

Attachment style	Caregiving experience	Presentation
Secure	Parent reliably responsive and attuned to infant/child's physical and emotional needs.	Child with a sense of trust that their needs will be recognised and responded to appropriately.
Insecure—Avoidant	Parent who is experienced as rejecting, interfering, and controlling. Child's distress seems to annoy or upset caregiver.	Child who denies or does not communicate their needs as they fear they will upset their caregiver by doing so. In older children and adolescents...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I: PRIVATE PRACTICE WITH CHILDREN AND YOUNG PEOPLE
• PART II: ETHICAL ISSUES IN COUNSELLING CHILDREN AND YOUNG PEOPLE IN PRIVATE PRACTICE
• PART III: PROFESSIONAL ISSUES IN PRIVATE PRACTICE WITH CHILDREN AND YOUNG PEOPLE
• PART IV: WORKING WITH TECHNOLOGY IN PRIVATE PRACTICE WITH CHILDREN AND YOUNG PEOPLE
• APPENDIX Useful resources
• REFERENCES
• INDEX