Community-Based Psychotherapy with Young People

Evidence and Innovation in Practice

Geoffrey Baruch

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9780415215107
• eBook ISBN: 9781134609178
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Community-Based Psychotherapy with Young People offers a fresh perspective on working with difficult groups of patients. Focusing on the work of the Brandon Centre for Counselling and Psychotherapy for Young People in London, the book describes approaches and techniques for working with young people with mental health problems. The book is divided into three parts: Part 1: covers the likely problems and difficulties encountered in such work. Part 2: describes services for high priority groups of young people, including those who are disabled or from ethnic minority backgrounds. Part 3: describes how the Centre evaluates the outcome of its work, and considers the future for other community-based organisations.The book will prove essential to all professionals wanting to explore different and effective ways of working with young patients.

Part I
Theoretical and practical aspects of engaging young people in treatment

Chapter 1

Engaging troubled adolescents in six-session psychodynamic therapy

George Mak-Pearce

THE PROBLEM OF ENGAGEMENT OF ADOLESCENTS

This chapter considers the question of how to engage psychodynamically in a timelimited intervention with young people aged 12 to 25 years. The question of engagement came to the fore following a review of attendance for psychotherapy at the Brandon Centre. This review is described in more detail in the Introduction to this book. One problem, no doubt familiar to other psychotherapy services for young people, was that demand for psychotherapy exceeded the resources that we could provide. As a result many young people’s requests for help did not get a rapid response. Another key area highlighted by the review was the high drop-out rate early on in the therapy.

High levels of attrition during the engagement phase of therapy is wasteful and damaging not just because the session times are lost (whilst there are many waiting who could use the therapy) but because one suspects that those who drop out are often those in greatest need of help. Moreover, experience has shown that those with pernicious problems in adolescence do not simply ‘get better’ later on in life. Healing does not occur simply through a process of maturation. As discussed in the Introduction recent studies have shown that disorders in adolescence, if untreated, continue into adulthood with similar or increased severity. Problems do not ameliorate without treatment and consequently the high attrition rate is, in effect, a ‘storing-up’ of problems for the future.

These considerations led the Brandon Centre to introduce a rapid response project with the aim of improving both take-up and engagement of young people. Any young person approaching the Centre who has not had previous experience of counselling or therapy, or who seems at risk of harming either themselves or others, is placed on a six-session waiting list. The waiting time for the first session is then usually up to 4 weeks. The young person is offered once-weekly meetings for 6 weeks. After the six sessions are completed they have the option of being put on the waiting list for longterm, once-weekly therapy. Therapy can then continue either with the same or a different therapist. The length of the wait between the six sessions and the longer-term work is usually about 8 weeks. This structure has proved effective in reducing waiting times but to reduce early drop out requires effective engagement of the young person in therapy and to this matter I now turn.

ENGAGEMENT AND FEAR OF THE FUTURE

Messer and Warren (1995) describe starting work with adolescents thus:

Adolescents can be especially difficult to engage in psychotherapy. They are often counterdependent and oppositional, struggling to develop autonomy and independence from parents. They also may be anxious about losing control, being controlled, or experiencing shame and inadequacy. The idea of revealing one’s concerns to an adult is filled with the unconscious dread of infantile regression and loss of a new-found and tenuously held sense of self. (p. 305)

In addressing the issue of engaging young adolescents psychodynamically within a time-limited framework I want to draw attention to what, I believe, is a critical feature of this phase of life. This is the intensity of the young person’s anxieties about how they will perform in the future. Adolescence is essentially a period of abrupt and dramatic changes to both psyche and soma. These changes are cognitive, emotional, social, physical and sexual. There are intense anxieties about future performance, in particular how to establish a degree of social status, a favourable ranking with peers and how to establish a sexual relationship. The young person has to negotiate new responsibilities and manage a burgeoning physical, sexual and intellectual potency. It is a time for dreaming of the future; equally it is a time of nightmarish anticipations.

Starting therapy can provoke unrealistic dreams and nightmares! A young person may approach therapy with trepidation or false bravado. It is not difficult to picture the 16-year-old who might start by saying that he didn’t want to talk about his feelings but what he could do with is sorting out a set of wheels and a place to live! What do we do with those situations where there is an apparent chasm between the client and the therapist in their understanding of what psychotherapy may provide? How does one move towards a therapeutic relationship? Many of the obstacles to engagement that one may suppose—for example that therapy will dig up the past, create shame, inadequacy, or dependency, cause infantile regression or loss of sense of self—are all fears that can apply at any age. What is the pertinent characteristic of adolescence that explains the high drop-out rate? I have chosen to approach this question by focusing upon the intensity of the adolescent’s fear of the future. To look into this fear I shall start with issues to do with attachment and rank.

ATTACHMENT AND RANK

Early attachment experiences, as Bowlby (1982) argued, are deeply pervasive in our capacity to establish and maintain future relationships. So where mother-child bonding has been significantly disrupted the individual is prone to form what Bowlby called ‘anxious attachments’. Such individuals may feel lacking in confidence, insecure, shy or hostile. In more extreme circumstances they may become phobic, anxiety-ridden, depressed, or conduct-disordered. I am sure most psychodynamic therapists are sensitive to and listen out for indications of early attachment difficulties. In particular, attachment issues tend to get played out in the transference and thus can strongly influence the young person’s anticipation of the future of the therapy and how it will end.

Issues of rank are to do with how one perceives one’s social standing, one’s sense of self-esteem, status and entitlement. Stevens and Price (1996), who develop an evolutionary perspective, have recently emphasised the significance of rank in mental health. They argue that being able to accurately sense and respond to one’s rank and status with peers and with the wider society is a good indicator of mental health. Whilst such skills are important at any stage of life, to my mind they are acutely so for the adolescent. This is so because the young person, on the cusp of adulthood, can be in the confusing position of sensing life holds great potential whilst at the same time sensing that their actual social status is at an alltime low. One 16-year-old girl who had recently left care put it succinctly in her first session when she said of herself ‘I could be Whitney Houston, not a total zilch!’

I am sure it is not contentious to emphasise that adolescence is generally a time of low social status. Equally it is generally a time of (unrealistically) high individual expectations. This clash can generate great turmoil. One has lost the ‘charm value’ of being a child but the compensating values of adult social competence and emotional tolerance are frequently not exercisable with any confidence. Even for those young people who are safely within the social norms for their age, leaving school or leaving university and starting employment they are generally ‘at the bottom of the pile’.

A more devastating downward shift in social status but upward shift in expectations can pertain for those from more deprived backgrounds. Those who are socially excluded, have little education or employment prospects and may already have a criminal record stand a high risk of finding themselves destitute. Statutory provisions for those reaching age 16 abruptly change and homelessness for this age group is high. Unemployment, poverty, the risk of being mugged, attacked or raped is at its peak. Yet even so expectations increase. The young person leaving school or care is expected to budget, shop, cook and find work. The need to belong to a group or gang can become urgent; particularly where such a group has its own mores through which one can quickly gain status and acceptance. Many ‘bold’ and illegal acts are performed to win the kudos and admiration of peers.

How issues of rank manifest themselves in the therapy will be fashioned in a complex way by the client’s attachment history, their age and other individual traits. Yet one truth that inevitably prevails is that the therapist out-ranks the client. The younger the client the more this is so. I state this rather obvious point because there may be many pressures upon the therapist that tend to inhibit awareness of ranking differences. Some that I have been conscious of within myself are a reluctance to be seen as an authority figure, a longing to be young again or over-identification with the adolescent phase of life, and, of course, projective identification with the client’s own sense of worthlessness and low status.

For the young person entering therapy, especially when it is for the first time, the ranking difference can exacerbate those factors that make therapy and the therapist seem threatening. This in turn can evoke the more primitive responses to a sense of being under threat; namely to fight back, behave submissively or flee. Whilst fighting back or being submissive can be worked with, the latter option leaves the therapist with an empty chair. In any event issues to do with rank can quickly evoke the deeper and darker elements of earlier attachment experiences and a concomitant dread of the future.

FEAR OF THE FUTURE IN TIME-LIMITED THERAPY

It may be supposed that the six-session structure would give relief to certain anxieties about engagement with the therapist. The fear of being trapped, becoming dependent or too regressed, would be abated by a time-limited setting. This has not been my experience. If anything it seems to me that the emphasis upon a time limit tends to evoke such feelings, can provoke performance anxiety in the client and, equally damaging, performance anxiety in the therapist. Am I, the therapist, able to provide enough? Are the sessions too intensive or perhaps not focused enough? Is there time for some working through of transference issues? There are myriad questions and it is easy to enter a short intervention with a sense of pressure, ambition or at least a full ‘agenda’.

Clients sensitive to such pressures can easily (mis)understand them in terms of their own performance. Thus they may feel they ought to quickly ‘get rid’ of problem X or ‘stop feeling’ Y or ‘solve’ conflict Z. In reality the therapist may be attempting to elicit, explore and ‘stay with’ problem X, feeling Y or conflict Z. This divergence can lead to all kinds of problems for engagement.

In time-limited therapy anxiety about performance and outcome—both the client’s and the therapist’s—can be present from the outset. It may just take the form of a vague but pernicious fear of the future. The task, it seems to me, is to be able to convert this vague fear into a more specific, articulated fear of engagement. And this is most directly tackled through talking about the fantasies of the future relationship. Of course exploring future fantasy is only one of many possible ways to approach such fears, but it is one that it is hoped will engage the person quickly and therapeutically.

It is particularly important in time-limited work that future fantasies of success and failure are made explicit and treated with openness and humour. In the process of doing so there is scope for playfulness and togetherness. When spoken about, future fantasy can portray both hope and despair but be free of the humiliation and pain connected with events that have actually happened. The work can be more ‘plastic’; future fantasies can be treated with a freedom and exploration not so readily permitted in talk of the past. Likewise the transference that ‘will be’ is open to being talked about if the therapist is prepared to introduce the subject in an easy manner. Let me expand on this.

FUTURE TRANSFERENCE

The future transference is a term I use for the current feelings about how the relationship with the therapist will be at some point in the future. To my mind it is the key to engagement, for in actuality the therapist and client do have to share a future time together in order to work, they do have to negotiate issues of attachment and rank, and do have to end and separate. What kind of figure will the therapist be? How potent, how useless, how intimate, how loved, how hated will the therapist be? What is the perceived value of the therapist as a potential introject?

It has been almost universal in my experience that the younger the person the less notion they have that it is desirable, permitted, or indeed relevant to explore their feelings about the therapist. It is of necessity a sensitive and delicate task on the part of the therapist to present in a meaningful way that exploring such feelings is a useful part of the work. I have found this especially important but difficult for those under the age of about 16.

A 13-year-old boy I saw, who seemed intelligent but bossy, was keen to quickly set out a problem he had. The hope was that I would have practical advice that would help him. He launched into a very detailed and elaborate account of how his best friend had rejected him. The story went on for some time and I found I was losing track. I also found myself waiting for him to move on to what I would consider more ‘important’ things such as his family relationships. I made some comment about the best friend and with a look of disappointment he told me I had got it all wrong. I hadn’t understood the situation at all. He went over it again in even greater detail.

My first reaction was to feel irritation and a need to reassert myself. I wanted to point out to him that I knew from the referral note that there were other more serious things going on in his life and within his family. But how should we decide what was spoken about in the session? He wanted to speak about his friend but I thought he was avoiding speaking about the family trauma. I discussed with him my concerns about the seriousness of the issues that had been mentioned in the referral note and then posed it as a question ‘how should we decide what to focus on?’ He replied that I should decide because I was the therapist.

Part of my reluctance to focus on the friend issue was that his expressed hope was that coming to therapy would result in winning his friend back. I felt I was seen as some kind of ‘tool’ that could be used to fix reality, a reality that was broken down, not working in the way he wanted. I was bound to fail. I decided to shift the focus towards his view of the future. I asked him how he imagined he would feel about me if at the end of the six sessions his friend was still rejecting him. He said, genuinely, that he would be very disappointed. He then added that at least we would have tried. The use of the word ‘we’ was the first indication of him seeing us as working together or at least being able to share a sense of failure together. So I agreed to stick with this issue.

We spent much of the six sessions talking through how he felt about this friend and what he could try to do to change things. He came up with the idea that while he had lost a friend, equally upsetting, he had lost status in his peer group. He was lower in the pecking order; he had been displaced in the gang and fallen out of favour. He came up with what I thought were some rather creative strategies to win his friend round. But, by the end of the six sessions he had not repaired the friendship—at least not in the way he had intended.

Yet there was a modest shift in the way that he felt about the loss of the friendship. Instead of only representing confirmation of his worthlessness he saw that the loss resulted from him expressing unpopular views. These unpopular views, however, were views that he believed in and that expressed his individuality. Following from this he was able to reassess the apparent loss of status within the gang and see that perhaps his growth and development represented a threat to a rather immature gang mentality. Internally the loss of the friendship became the price of progression towards a more autonomous future.

In this case exploring aspects of fantasies about the future helped develop a positive engagement in the here and now. In the next section I look at what could be called the negative future transference and try to separate out two forms this can commonly take.

SOME ILLUSTRATIONS OF NEGATIVE FUTURE TRANSFERENCE

Fated transference

Peter is a man in his early twenties who came looking for help because he was failing at university. Peter told me that throughout his life he had fought to gain independence. He had struggled to get to university, which represented freedom and future advancement. But now he was at university he had become deeply unsure of his worth. He felt his family expected him to fail and anticipated a humiliating ‘I told you so’ response from his mother.

His manner towards me was tired and passive. Yet he was quite specific about what he wanted: I should help him structure his time and give him the will power to get on with his studies. I should save him from a humiliating failure. On the surface this expectation can be seen as simply naive but otherwise reasonable. On a deeper level I felt he wanted to merge with me. I felt he wanted his failure and humiliation to become my failure and humiliation. Perhaps to triumph, perhaps so as not to feel so alone, perhaps to observe how I deal with and contain the pain, perhaps so he could say to me ‘I told you so’.

There are many things that could be said about the above expectations and how they fit into the question of how to engage with Peter in therapy. Here I wish to draw attention to the predominant sense of being with Peter, namely a very depressed sense that whatever happened in therapy was fated—fated to humiliation and failure. Peter presented as a passive recipient of a future scripted by others. This maybe echoes an early attachment relationship that felt engulfing and controlling. It also seems to goes hand in hand with low self-esteem and a poor perception of potential social rank.

In thinking about this kind of initial presentation I have found very useful the notion of fate that has been carefully and elegantly distinguished from the notion of destiny by Bollas in his book Forces of Destiny (1991). In essence, where we do not feel that we are the authors of our future lives, where we feel that the script is already written and that things are done either to us or for us, we feel fated. Fated as, for example, Oedipus was fated to do the things he did. A sense of destiny, on the other hand, implies a feeling of freedom and potency in the future, a sense of authorship of the story of one’s life, a sense that Bollas links with the Winnicottian notion of true self:

A person who is fated, who is fundamentally interred in an internal world of self and object representations that endlessly repeat the same scenarios, has very little sense of a future that is at all different from the internal environment they carry around with them. The sense of fate is a feeling of despair to influence the course of one’s life. A sense of destiny, however, is a different state, when the person feels he is moving in a personality progression that gives him a sense of steering his course. (p. 41)

Peter wanted recognition, independence and acceptance. He wanted his peers to rate him as worthwhile. However, he seemed fated to form merging relationships to provide security at the cost of autonomy and status. In his mind, accepting help from me equated with passively following my script. Naturally he resented being in this position and therein lay the threat to engagement in therapy.

It was through a detailed and explicit discussion of the implications of this stance to our relationship that he began to shift. Gradually the fantasies about what lay ahead broadened and diversified. By having a focus upon the future relationship somehow we were abl...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Figures
• Foreword by Peter Wilson
• Foreword by Peter Fonagy
• Preface
• Introduction
• Part I Theoretical and Practical Aspects of Engaging Young People in Treatment
• Part II Services for High Priority Groups of Young People
• Part III The Evaluation of Mental Health Outcome
• Part IV Conclusion