Reflective Practice in Child and Adolescent Psychotherapy

Listening to Young People

Jeanine Connor

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429624179
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Therapy referrals for a child or young person can be motivated for a number of reasons. The parents, carers or professionals responsible for their wellbeing might describe a sudden change in presentation, risk taking behaviour, such as self-harm or experimentation with drugs, alcohol or sex, or they might label the young person as over reacting, under reacting or attention seeking. Such behaviour prompts concern for their safety and confusion about why the child or young person is presenting the way they are. This book offers a thoughtful approach to making sense of such behaviour and encourages adults to 'reflect on' rather than 'react to' young peoples' outward presentations.

Based on the author's work with children, young people and families over two decades, this book shares reflections from the therapy room and illustrates how the therapist can try to make sense of mood, behaviour and presentations that previously made no sense. The content relies heavily on clinical experience as well as drawing on classical and contemporary psychotherapeutic literature.

So often adults find themselves reacting to observable behaviour in a judgmental or punitive way, rather than pausing to consider what the behaviour might be communicating. The author aims to model a thoughtful reflective approach to making sense of what might be going on for children and young people and this book will be of great interest to child and adolescent psychotherapists, related professionals and those with an interest in young persons' mental health.

Chapter 1

Psychotherapy with children, young people and families

Psychotherapy with children and young people is different to psychotherapy with adults. It requires a different set of skills and a different kind of patience and perseverance. It is infinitely more complex than working with adults because a child is always part of a family system in some shape or form that will be involved in the therapeutic work both directly and indirectly. The child and I will welcome some involvement from the family, while other involvement can feel intrusive or sabotaging. Sometimes I work with a parent and child together; other times just a parent or parents to support them to think about their child’s difficulties. When I offer individual work to a child or young person I always include the parents or carers at the beginning and the end and at review points throughout the therapeutic intervention. It is important for parents and carers to feel as if they are included in the wok; they are responsible for their child’s safety, including emotional safety, and they too might be struggling to make sense of what is going on for their child. I am not a substitute parent, I am a psychotherapist and we have different yet complementary roles. It is important to acknowledge that to parents and carers from the start; some of whom think it is my job to ‘fix’ their child and then hand them back without taking any responsibility themselves. Others feel pushed out by this new adult in their child’s life who their child is opening up to in ways they can only dream of. These are extreme ends of the parental spectrum, of course, and most parents fall somewhere in between. They want to make sense of their child’s behaviour, thoughts and feelings, and they want to have a better relationship with them, but they are struggling to know how to achieve that. The other thing that is important to note is that psychotherapy changes people and this has a ripple effect on the people around the person in therapy: the people in their family system. I sometimes use the analogy of a machine made up of cogs, a bit like the inside of a clock, to describe a family system. If one of those cogs – the child in therapy – changes shape, it might not fit with the other cogs the way it once did and they too will have to adjust their shape to make sure the machine can still function effectively. Just as cogs in a machine, people in families impact every other component in their system.

A lot of my work is with children who no longer live with their birth family because they are in foster or residential care. Looked after children often have multiple families that get ‘brought’ to therapy one way or another – in reality, in fantasy, in thought, in play or in the transference relationship. Their system is made up of previous and current carers as well as previous and current social care professionals. All of these adults will have had an impact on the young person and he or she on them. A lot of looked after children get moved around an awful lot between family systems and so they are constantly being expected to change shape in order to fit in with a differently shaped machine. Often this is too difficult and they get moved again. Often they don’t know how to fit in with a new family because they don’t know what shape they are expected to fit into. Often, by the time I meet them in therapy, they are confused about their own identity, shut off emotionally and highly defended against forming another relationship with another adult, not knowing what they expect from them either.

Jay

So what is psychotherapy with children and young people actually like? Those I work with often use metaphor to describe their experiences of psychotherapy. Some mention the ‘wounds’ they have suffered, and liken the therapeutic process to ‘picking at’ or ‘uncovering’ something difficult. This sounds painful, and of course therapy often is. Some children and young people try to protect their emotional wounds with a psychological sticking plaster. This is an attempt to cover up the hurt but we both know it is still there, just beneath the surface. As ten-year-old Jay told me in an initial session,

If I take the plaster off now, it will just bleed and the badness will fester away inside me.

I think this was his way of telling me he wasn’t ready to show me his wounds yet, which I respected, and that he wasn’t sure if he was ready or able to heal, or whether therapy would be able to help him. It is important to acknowledge the client’s uncertainty about therapy and mine too because I can never be sure whether a young person will find therapy helpful, no matter how much I want that to be true. Jay was also alerting me to the ‘badness’ he felt he had inside of him that was festering away and preventing him from healing. There was also a warning that if the plaster was removed too soon he would bleed; alerting me to the fact that it could get messy and that he couldn’t be sure whether either of us could handle that just yet. What Jay bravely shared with me in that initial meeting was that his wounds were real, hurting and disgusting. I listened to his communication and I respected it. Jay and I worked together for twelve months exploring and making sense of, mostly through play and metaphor, his early experience of sexual abuse.

Jack

Another boy of the same age, Jack, arrived at his first session and showed me all the cuts and bruises on his legs that he had sustained through playing football. This became a ritual at the start of every session as he became increasingly committed in his determination to up the bruise count each week. Sometimes I struggled to see the tiniest of abrasions that Jack insisted were there. One week he asked if I had any plasters. I did, in a small first aid kit I keep on hand. He took out a strip and spent the session locating his bruises and sticking plasters over them. By the end of the session he had used up the whole pack! The next week, having replaced my stock of plasters, we went through the same ritual of locating and counting cuts and bruises on Jack’s legs. By about the fifth session I was invited to put the plasters on Jack’s legs instead of him doing it for himself. When a pattern of behaviour is repeated in therapy it is important to stay with it and observe. When it changes, however subtly, it marks a psychological shift. What happened in the first weeks of Jack’s therapy felt like a deeply symbolic process. I was invited by Jack to acknowledge his wounds. Some were clear to see but others were barely visible although he insisted they were there. I listened to his communication and acknowledged that it felt important to him for me to see his injuries. This is symbolic of what can often happen in therapy. A young person is referred with a presenting issue – the wound that is clear to see – yet over time, other wounds show up that were less apparent or which the young person had kept hidden. With Jack, I made comments like,

I can see some of these bruises really clearly, but others are harder for me to see.

This was true but non-shaming. I wasn’t saying the other bruises weren’t there, just that I struggled to see them. I wondered about the symbolic communication of witnessing Jack covering up his wounds with plasters. Perhaps he was saying,

You can’t help me, I have to do this for myself.

Or perhaps he was telling me,

I’m keeping some of this hidden from you for now.

When the plasters ran out, I experienced a strong sense that my meagre resources might be an insufficient match for Jack’s multiple layers of pain. It is not uncommon for me to wonder – and sometimes worry – about whether I will be able to help a child or young person when I meet them for the first time. But with Jack I felt this more strongly which suggests I was experiencing a projection of his own fears and anxieties about how helpful therapy could be. He was pleasantly surprised when I replenished the stocks in readiness for his next session and I think he understood my response (symbolically) as a communication that it was ok to take what he needed from me and that he wouldn’t use me up. When finally I was invited by Jack to share in the process of providing first-aid, it felt like the perfect metaphor for Jack’s readiness to begin therapy – which is always a collaborative process of making sense and of healing.

Other children and young people arrive for their first session protected, not by a metaphorical sticking plaster, but by much strong psychological defences that have served to protect them from emotional and sometimes physical pain. They might liken these defences to shields or armour or ‘one million metre high walls’, which was one young person’s, not so subtle, way of warning me to keep out. It is important to acknowledge these communications and respect young people’s defences. Stealing away their shield or asking them to remove their armour would leave them vulnerable, while taking a metaphorical sledgehammer to the walls they have spent years erecting could replicate earlier psychological damage and remove any hope of building a therapeutic relationship. If the time is right for a child or young person to start treatment, and only they can know this, I respect the defences that have served them well enough for long enough. I position myself alongside them as they start to slowly remove the plaster or take down the walls, brick by brick and reveal the wounds beneath in their own time. For some children and young people, like Jack, this can take weeks and for others it takes months or even years. According to the child or young person’s own agenda of time, we examine the wounds as and when they are ready and we make the therapeutic journey together.

I remember being encouraged as a trainee therapist to have faith in the therapeutic process. I had no trouble comprehending the theory but this thing my tutors called the ‘process’ was an enigma. I think now that it is about disentangling the content of therapy from the thinking-about therapy. Initially, most of the processing happens outside of the consulting room in private reflection and/or in supervision, but with increased clinical experience, the doing and the thinking-about become reconciled. For me, the process has a unique identity that is linked to, yet also distinct from, the content. I often find myself thinking about this with parents and carers of the children and young people I work with and it can be a difficult concept to explain and understand. Not surprisingly, the adults around the client want to know what happens in therapy and, more importantly, whether it is working. It can be difficult for them to comprehend what isn’t tangible and to have faith in a process they aren’t privy too. Most children and young people I work with seem to ‘get’ the therapeutic process instinctively. They can sense it, even though most of them would struggle, as I sometimes do, to explain its ‘magical’ quality. But there are some children and young people whose conscious or unconscious intention is to attack the process, such as the child who wants me to set the agenda, or the concrete-thinker who draws me into philosophical debate or logical argument in lieu of emotional connection. Or the young people who fill the session with talking and over-explaining and over-detailed accounts of he-said/she-said. In sessions such as these I find it hard to concentrate on what is being said, frightened I might mishear or misremember something when I write up my notes later. But then I remind myself that the verbatim account of what happened – or didn’t happen, who am I to say? – is not what’s important. What is important is how the session feels, what sense I make of it, or not. It is more important to notice the process of what’s going on than get caught up in trying and failing to listen to the content, which is serving as a defence. Children and young people who fill the session up are keeping the emotional parts of themselves shut-off and trying to keep the thinking part of me shut-out. This is part of the process too, of course. Although it can be difficult to sit with, that is what I am being invited to do in these sessions. When I feel as if I’m being drawn into, or pushed away from something, I try to keep the thinking-part of myself alive and provide a commentary to the here-and-now. I might say something like,

It seems like it’s easier for us to think together today rather than feel.

Or,

I’m getting a sense that you don’t want me to think very much today.

That way I’m reflecting on the process, even though the young person is trying their best to sabotage it. This is often unconscious on their part, and comes as a consequence of well-practiced strategies that serve to protect them from painful emotions. As with other defences, I respect them but I do not ignore them. I say what I notice but I don’t force a young person to go where they are not yet ready to go. It is their process, not mine.

There are other children and young people for whom the avoidance of the process is more blatant. The boy who yelled at me,

Why do you have to analyse everything I say?

And the adolescent who screamed,

There is no such thing as the fucking unconscious!

right in my face.

These young people were focussing on the content of the session and finding it difficult to contemplate the process. Perhaps that would have been too unbearable.

Priya

The antithesis of the child or young person who attacks the process with filling up the content is the one who creates an empty void. I understand this as an unconscious replication of the psychological empty void they carry internally. I remember an early adolescent client, Priya, who I worked with many years ago for several months. She attended every session and mostly sat in silence while I mostly sat in silence too. I didn’t know what to do. I didn’t know if therapy was helping her or whether I should continue seeing her. I reduced her sessions from weekly to fortnightly because I thought the frequency might feel too intimate and that it could be affecting her capacity to engage. I thought about ending therapy altogether because, well if I am honest, I didn’t find it very satisfying. Every session left me feeling drained and often with a headache. It felt pointless. We weren’t talking or doing anything and there is only so much silence I can listen to. I felt like I wasn’t good enough. When I pushed aside the content and reflected instead on the process, I was able to understand it as a mirroring of Priya’s experiences. Only then was I able to sense – and make sense of – what was going on.

Priya was a looked after child who had experienced multiple placements and been excluded from school. Her sixth social worker had resigned and not yet been replaced. She had sporadic contact with her parents who were separated and each had new partners and new children; Priya’s half siblings who seemingly took priority over her in their parent’s lives and minds. I felt an immense sadness in relation to Priya’s repeated experience of rejection and abandonment. I thought her sense of being un-wantable must be overwhelming and her projections so powerful that I hadn’t wanted her and had considered abandoning her too. It is remarkable how the therapeutic relationship mirrored Priya’s other relationships where contact had been reduced or terminated and where new siblings had replaced her. I had also considered getting rid of my unsatisfying client in order to make space for a new, potentially more rewarding one. But I contained Priya’s projections week after week, which demonstrated to her my willingness to bear them. I had felt useless, hopeless and deskilled, just as she did, but I had endured those feelings alongside her. At other times I had felt punishing and hating but I had resisted the temptation to punish Priya by rejecting her. Much of the communication between Priya and me was unconscious and non-verbal, and most of what happened was in the rich therapeutic process rather than the empty-feeling content of the sessions. Priya must have sensed that too – why else would she have kept coming back? My feeling was that she experienced something nurturing in our therapeutic relationship. There was no agenda and no rules about right or wrong, she could just ‘be’ and perhaps, most powerfully of all, experience another person just being with her too. She had not said very much but I had still listened and made sense of her internal world. How valuable the therapeutic space must have been for Priya, a girl who lacked any consistent, dependable, safe spaces, and what a wonderful thing to be able to provide for her.

Trudy

My work with Priya mostly took place in the transference relationship at an unconscious level. There is always an unconscious element to comm...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Disclaimer
• Preface
• 1 Psychotherapy with children, young people and families
• 2 Fantasy and lies
• 3 Labelling children and young people
• 4 Sex
• 5 Identity
• 6 Play
• 7 Endings and loss
• Index