Psychodynamic Counselling with Children and Young People

An Introduction

Sue Kegerreis

• Publisher: Bloomsbury Academic
• Year: 2009
• ISBN:
  9781350305939
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Introducing key psychodynamic theory, concepts and techniques, this text examines the challenges and opportunities of counselling adolescents and children. The book explores a wide variety of settings and contexts, from schools to community projects and mental health services. It is an invaluable guide for counsellors and therapists at all levels.

PART I

KEY THEORIES AND TECHNIQUES

1

INTRODUCTION

The need for childhood counselling

The worrying prevalence of child and adolescent emotional difficulties is now widely recognised. The often quoted figure given by the UK Office of National Statistics 2004 is that 1 in 10 young people suffer severe mental health problems. There have also been increasing indications that disturbance is being experienced, expressed and therefore picked up by concerned adults at ever earlier stages of development. Primary school staff are receiving children aged 4 and 5 who are already significantly concerning. In January 2008, just under 150,000 children in UK primary schools were assessed as having behavioural, emotional and social difficulties – and this only covers those having Special Educational Needs status of ‘school action plus’ and Special Educational Needs statements. Therefore the total number of children with such difficulties is likely to be far higher (DCSF 2008). In UK national statistics and in the study by Meltzer et al. (2000), it has been found that 10% of boys and 5% of girls aged 5 to 10 have a mental disorder, and by the age of 11 to 16 the proportions were 13% for boys and 10% for girls.

There is much debate as to why this might be. Recent enquiries have stressed how modern society has a tendency to fail our children in providing for their emotional needs. (Children’s Society 2009, Unicef 2007). Key predisposing factors identified as independently associated with increased rates of childhood mental disorders by Meltzer et al. (2007) ranged from ‘characteristics of the child (age, sex, physical health problems, having poor scholastic achievement) to family characteristics (family structure, mother’s psychological distress, poor family functioning) and household characteristics (tenure, type of accommodation and the working status of family)’. An earlier study (Meltzer et al. 2000) identified parental unemployment, parental psychiatric disorder, sole parenting, reconstituted families, large families with more than 5 children, low income and low socio-economic status as key factors. What is clear is that families have been changing over the last few decades, which has led to an increase in instability for children through higher rates of divorce and family breakdown and changing patterns of employment. Family breakdown is a stress in itself, but in addition it is strongly associated with poverty, which UNICEF highlighted as an overriding indication of vulnerability in children (2009).

As a result of changing family structures and employment and financial pressures on family life, children are being placed in institutional care such as nurseries for longer periods and at earlier ages. Twenty-four percent of children are being brought up with a single carer, which decreases the support available to the parent and family, and this, among the other major pressures on all families to earn enough to keep going, leaves ever more children spending less time with parents. There are strong correlations between parental breakup and emotional difficulties, even if some children have the resilience to manage family breakup relatively well (Pedro-Carroll 2005). Research has shown a strong correlation between time spent by parents with their children and educational attainment (Guryan et al. 2008). Time spent is of course not in any simple sense a measure of relational health, but it is an indicator of the emphasis on relating in the family. Penelope Leach (2009) found that the average time spent between parent and child dropped by 40% between 1973 and 1993, although the proportion of time spent by fathers with children has increased. Parents who are physically and emotionally exhausted, busy, absent or preoccupied with coping with the practicalities of life are unable to offer children as much in both quantity and quality of interactions. There are quantitative measures of how much less verbal children are at entry into school, especially amongst the lower socio-economic groups, and while this does not itself indicate emotional problems, it is a reasonable conclusion that verbal ability has a link to the capacity to make and manage relationships and connects with how much the children have been spoken to and listened to.

Furthermore, there is solid evidence (Meltzer 2003) that there are strong continuities in the prevalence of problems. If children do not get appropriate and effective help early in life, there is a far greater likelihood that they will continue to have problems for the rest of their lives. A telling statistic is that 95% of young offenders have mental health problems (YM 2008). Eighty percent of children showing behaviour problems at 5 years of age go on to develop more serious forms of anti-social behaviour. These children need help before their problems become firmly established. As reported in The Good Childhood Enquiry (2009), only a quarter of children that are seriously troubled or disturbed by mental health difficulties are getting any kind of specialist help. Services offering early intervention are badly needed.

In Every Child Matters (DfES 2003), the importance of early intervention and support for children was stressed and agencies working with children were urged to share information and provide services to children and families. Schools are required to offer extended services in an effort to assist all children in reaching their potential. There is the potential for educational, health and social interventions to be far more integrated than before, and this gives a huge opportunity to those who want to provide counselling to troubled children. Indeed, the Institute for Public Policy Research produced a report calling for there to be a counsellor in every school (2009).

Therefore, there is not only a significant unmet need for emotional help to be given to children, but also an unprecedented opportunity for this to be delivered where the children are and at an earlier stage.

This book is intended as an introduction to the theory and practice of psychodynamic counselling with children and adolescents. It is aimed at anyone who is in a position to work therapeutically with children and adolescents – in educational settings, child and family clinics, community agencies or anywhere else where troubled young people may be reached. It is also intended to be of use to those who may not be able to offer formal counselling or other therapeutic intervention, but for whom the psychodynamic approach could prove an invaluable tool in their demanding work with emotionally damaged and difficult children or adolescents.

Working with troubled young people can be painful and difficult. They can express their difficulties in ways that test us to the limit. Whatever our role, we need to equip ourselves with enough understanding so that we can think about what the children are communicating – whether this is through their behaviour, their difficulties or their effect on us. We need to be able to understand these communications, in order to avoid getting caught in a cycle of action and reaction. We need to be able to withstand the impact on us of their emotional pain, which can otherwise cause us huge stress, leading either to a defensive retreat into ‘managing cases’ or becoming professionally burnt out.

The psychodynamic approach is one that can uniquely help us, not only in helping the children directly through counselling but also in providing us with a framework that can improve our perceptivity and resilience, enabling us to keep on being able to work with them, keep on understanding them, and keep on being able to offer them a receptive, thoughtful presence.

Structure of the book – finding your way around

In Chapter 2, I will outline the key underpinning theories and concepts behind psychodynamic counselling, as it has evolved from its lineage of psychoanalysis and psychoanalytic psychotherapy. This will help the reader see how this approach helps us understand both personality and behaviour in a way that illuminates our thinking and provides tools for working with young clients. I will look at the unconscious, the inner world and containment. In relating this to the work we do, the reader is also introduced to the central ideas of transference and countertransference, as they are experienced in work with the children.

This leads on to Chapters 3 and 4, where the ‘psychodynamic toolbox’ is considered and described. Chapter 3 emphasizes those tools which are of use whatever the setting and whatever role we are in, while Chapter 4 concentrates on those which need to be more carefully handled, most probably in the context of the counselling room. Psychodynamic work offers a powerful set of approaches and techniques, which equip us with ways of getting more fully in touch with the children, in order thereby to help them navigate their way more successfully through whatever obstacles to development that are in their way. The psychodynamic approach also brings with it a particular view of a child’s emotional development, concentrating on the processing of both the conscious and unconscious experiences at each age and stage.

In Chapter 5, I will describe a psychodynamic view of child and adolescent emotional development, with a description of the key emotional challenges of each phase. In order to understand the troubled child or adolescent in front of us, we all need a good grasp of normal child development, of the inevitable conflicts inherent in growing up, and of the ordinary difficulties, anxieties and defences arising at different ages. This will immediately help us tune in more accurately to our young client, in that we will have a greater sense of what might be at issue at this particular stage of their life. Such a dimension to our awareness is also essential so that an appropriate assessment can be made of how severe the child’s difficulties may be.

Following on from this, in Chapter 6 there is a deeper look at the challenges of learning. This is central to the task of growing up, and is the arena in which so many children and adolescents experience frustration and failure. As many counsellors work in schools and universities, it is likely to be a key feature in those referred for help, even if the underlying emotional dynamics are manifesting themselves in many other areas of the young person’s life. A detailed understanding of how difficult and complex learning can be is crucial for anyone working with children or adolescents. There is, in addition, a direct connection between what makes learning difficult and what might get between the child and the potential benefits of counselling. As a result, this section also has a bearing on some of the dynamics around getting help that are likely to be aroused in the counselling itself.

Then we move on in Chapter 7 to a more detailed look at the tools of the trade, that is the use of play and art materials in work with children and adolescents. This is one area where the work can differ fundamentally from similar work with older age groups. Anyone working with younger children (although adolescents can also often make good use of art materials) needs to be able to understand play as communication and to interpret what is being expressed symbolically through art. We not only need to be able to pick up on what is being expressed in these ways, but also to be able to know what to do with this in the counselling room. We need to know how to play with the child in a way that is facilitating and helpful, which requires the capacity to have one foot in the game and one outside it, to be able to think and comment but also to take part.

Working with children has many differences from working with adults, and one key difference is in the area of difficult behaviour. Children’s problems will often not be something that they can describe and talk about, nor even something that they are able to play or draw about. They can only be acted out and dramatized through behaviour. In Chapter 8, I describe some of the challenges children can present in the work, and ways of thinking about responses. While adults can become violent, storm out, or otherwise break the boundaries of what is usually a talking encounter, children will much more frequently present challenging or disturbing behaviour that has to be managed by the counsellor. A psychodynamic counsellor has to find a way to respond that is constructive rather than punitive, thoughtful rather than retaliatory. Sometimes this will be through insightful interpretation, which will help the child stop the behaviour as he will feel understood, but for others this will be through appropriate limit-setting. Psychodynamic work is to do with understanding the meaning behind behaviour of whatever sort, and if difficult behaviour is managed well, then not only is the setting preserved, but the child is given a direct example of being contained, both in thought and action, without that meaning being denied.

Whenever we work with children and adolescents we are always highly conscious of the family behind them. Our understanding of the child and their relationship with us will be informed by a growing grasp of the family dynamics that have underpinned the child’s emotional development. The family is also the child’s first ‘group’ and many of their ways of coping with – or failing to cope with group life will have their roots in their family experiences. Children are in groups for much of their lives, and some have serious difficulties in group settings while being able to cope better in one-to-one encounters. Both for this reason, and because working therapeutically with groups can be beneficial for so many children, Chapter 9 looks at psychodynamic group work and group dynamics.

One of the other major differences between working with children and adolescents as opposed to adults is around issues of consent. Children and adolescents are most often sent to counselling by someone else, and it is often far from clear who the actual client is. The counsellor is not in simple dyad with the young person, but is more often in a complex constellation with either school or family or both. This requires professionalism and skill in the counsellor, and Chapter 10 explores some of the complexities around consent and contract in this work. It also considers some of the skills needed to engage the child or adolescents themselves so that, whoever the referrer, the young person becomes an active client on their own behalf.

Another area that can raise difficulties about being able to give and receive help is around the differences between counsellor and client. It is a truism in work with children that there is always going to be one difference – age – which sets up its own dynamic. However, there are also often going to be differences in ethnicity, gender, class, physical and mental ability, and life chances. With older children and adolescents, differences in terms of sexual orientation may also need to be carefully considered. Chapter 11 looks at the psychodynamic view of these issues and gives some idea of how to take up such issues productively in the work. We need to be aware of who we are in the children’s eyes, even before the actual therapeutic relationship has a chance to develop, if we are to understand and be able to work with the relationship in the room. We need to know how these both real and perceived differences between the child and others are making an impact in his life, and to have some understanding of the way in which they shape the child’s experience of his world. We also need to be alert to our own difficulties in the area of difference, and to be aware of how much work we might need to do within ourselves to remain fully available to the client.

Most counsellors working with children and adolescents are going to be working in organizational settings. If we are to be effective, we will need to understand the institutional framework within which we are practising and also that within which the children are living and experiencing their difficulties. We need to appreciate the way in which they and we are fitting in with or being acted upon by dynamics that are much larger than the individual. Otherwise we can be prone to misunderstand the pressures on them or interpret as purely personal issues that are part of the whole institution’s way of functioning. Each setting will provide its own context to the work that will have a powerful effect on both the counsellor and the child’s experience of the work.

In Chapters 12 and 13, I provide an outline of the particular issues, opportunities and constraints offered in some typical settings. This will also highlight some differences between counselling and psychotherapy, as the context in which the work is offered has a crucial impact on the style of work that will be appropriate. The setting will always raise issues around relationships with other staff, confidentiality, the sharing of the counsellor with other clients, the attitude of the institution towards the counselling, and of the place of counselling in the client’s mind. All these need to be understood and to be central in our thinking if we are to manage ourselves and the work professionally and make the most of the opportunities to help these particular children in this particular setting.

Thus far nothing explicit has been mentioned about the amount of time a child or adolescent may be in counselling. One of the differences often identified between counselling and psychotherapy is that the latter is usually longer-term. Open-ended or fairly long-term counselling is offered in many settings, but in some agencies and some circumstances it is required or recommended that the child or adolescent be offered short-term or time-limited counselling. In Chapter 14, I consider psychodynamic ideas useful in regard to such work. Issues around time are always strongly present in work with young people, as their own developmental and educational imperatives impinge on them and on the counselling. In schools the structure of the school year is always imposing its own rhythm, and the external pressures of exams and transitions from primary to secondary school, or from school to college, are always integral to the work. Furthermore, there is much to be gained from developing a skill in psychodynamic therapeutic interventions that can be short, as there are often times when a brief, focused piece of understanding can free up a young person who has become blocked by some developmental or emotional obstacle, enabling them to move on after limited intervention. Especially in adolescence, this can be a way for them to make use of help without becoming attached in an intimate relationship just as they are moving away from such dependence in their outside lives.

One of the crucial but sometimes neglected tasks for any counsellor meeting a new child or adolescent is to conduct a careful assessment, whether or not an explicit session or number of sessions is labelled as such. This is both to assess the suitability of the case for counselling input, including a risk assessment, and also to inform the style and direction of the work, if undertaken. Chapter 15 outlines central questions that need to be asked in the assessment phase, so that both counsellor and client can be sure that the work offered is appropriate and the beginnings of an understanding can be established. A good assessment can lay the foundations for focused and sensitive work, enhance engagement and ensure that the counsellor is making an informed choice about what is being offered, why and how it is going to be most effective.

In the final chapter, I will look at dynamics around ending a counselling relationship, both for the child but also for the family and referrers. For all children, but especially for those who have experienced powerful losses and separations in their lives, ending a relationship well can be of immense importance. Counselling gives a unique opportunity to work on what separation can mean and help children with their feelings of loss. However, endings cannot always be managed smoothly because children might leave abruptly for new schools, or other factors extraneous to the counselling might interf...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Part I Key Theories and Techniques
• Part II The Dynamics of the Counselling Relationship in Context
• References
• Index