Jeanine Connor is regularly commissioned to write articles for bacp journals Therapy Today and Children & Young People. These longer pieces (2000 - 3000 words) draw on theory and research related to pertinent issues affecting young people.

All works contain an amalgamation of therapeutic experiences. Events and individuals are unrecognisable. 

All words are my own and images are copyright free.

Fetishes and 



What's the harm?

Published in bacp Therapy Today, February 2018

It’s vital to understand self-harm as a way of coping, not as a suicide bid, writes Jeanine Connor 

When was the last time you knowingly did something harmful to yourself – smoked a cigarette or nicotine substitute; drank a glass of wine over the recommended allowance; swallowed a couple of paracetamol above the prescribed amount; took a recreational drug; skipped a meal or binge ate? Usually we do these kinds of things because we think they’ll change our mood in some way by helping us to unwind, de-stress, or relieve psychological pain. On occasion, we might do things we know are harmful in order to manage our emotions or dissociate from them. Is this self-harm?

Most people think of self-harm in terms of cutting or burning and associate it with adolescent girls, sometimes as a way of ‘acting-out’ and sometimes following a ‘copycat’ trend. All too often it’s labelled as ‘attention-seeking behaviour’ and is misunderstood or dismissed. Self-harm is far more complex than these simplistic stereotypes suggest, as I hope this article will illustrate, and it is prevalent across all genders, cultures and age groups. If we are to work with it, it is important that we counsellors and therapists are clear in our own minds about what we understand by self-harm, as this will influence our clinical work from contracting to discharge, as well as inform decision-making around safeguarding and disclosure throughout the period of therapeutic engagement.

In this article, I draw on a number of definitions of self-harm, mostly expressing or derived from a medical, diagnostic model even if they are written in lay language. While I do not necessarily endorse these definitions, they provide a valid starting point for a critical exploration of self-harm and how we can work with it safely, appropriately and therapeutically. They also remind us how our colleagues in mental health and medical settings may view it. As I work almost exclusively with children and young people, the clinical examples I include are from the adolescent age group, although similar models of working can be applied whatever the client’s age. These examples are amalgamations of multiple client experiences rather than identifiable individuals.


NHS Choices, the public-facing health information website, defines self-harm as ‘... when somebody intentionally damages or injures their body... usually as a way of coping with or expressing overwhelming emotional distress’.1 This is uncontentious but restricted and does little to inform our understanding or treatment of self-harming clients. 

The online Medical Dictionary is more nuanced, defining self-harm as: ‘The deliberate infliction of damage or alteration to oneself without suicidal intent, in particular by those with eating disorders, mental illness, a history of trauma and abuse e.g. emotional or sexual abuse – or mental traits such as low self-esteem or perfectionism.’2

Both these definitions lay stress on ‘intentional’ or ‘deliberate’ which for many, have judgmental resonances. While there has been a welcome shift away from ‘deliberate self-harm’ (DSH) in some settings, the new language of non-suicidal self-injury (NSSI), which feels less condemnatory, is taking a while to become fully embedded. 

I contest the use of the word ‘alteration’ contained in the Medical Dictionary definition, as would most of my clients. I have debated with counselling and psychotherapy colleagues whether tattooing, piercing, ear stretching or cosmetic surgery are forms of self-harm. To me, even people who go to seemingly extreme lengths of piercing and stretching to alter their body and/or face are not demonstrating self-injury. The crucial difference is the motivation, which for these individuals is to enhance and embellish their bodies rather than harm them, however extreme their methods might seem.

I also find problematic the suggestion that self-harm often accompanies eating disorders (although, confusingly, eating disorders are sometimes described as a form of self-harm3), mental illness, or a history of trauma and abuse. I think that this definition perpetuates an increasing trend towards pathologising behaviours that, seen from the individual’s perspective, may be regarded as an understandable response to an unbearable situation. Pathologising suggests that someone who self-harms is ill. Some people with a diagnosed eating disorder or mental illness might self-harm and the behaviour could be an expression of trauma, but that is not the place from which to start the conversation.  It is helpful to note that the National Institute for Health and Care Excellence (NICE) states explicitly that: ‘Self‑harm is not used to refer to harm arising from overeating, body piercing, body tattooing, excessive consumption of alcohol or recreational drugs, starvation arising from anorexia nervosa or accidental harm to oneself.’4

I considered this definition useful in my work with Dan, a 19-year-old student who came to me for psychotherapy because of problems with intimacy. He was an unconfident, shy young man with lots of visible tattoos and enlarged earlobes through stretching. A couple of sessions into therapy, he arrived with deep scratches on his face, and told me he got them when he was drunk but couldn’t remember how. Later, he admitted that the scratches were self-inflicted, and over the following weeks his visible injuries became more extreme. He arrived at one session with a deep wound on his cheek having intentionally cut himself with a razor blade. Over several months of therapy, we worked through Dan’s hatred of his appearance and ambivalence about his sexuality. We disentangled the ‘alteration’ – tattoos and ear-stretching – from the ‘self-injury’. We explored the meaning of Dan’s behaviour in establishing his identity and I tried to encourage him to self-harm safely and helped him to find healthier and non-violent ways to express his emotions.

Ask the question

The Mental Health Foundation defines self-harm as: ‘... a wide range of things that people do to themselves in a deliberate and often hidden way’.5 I think it is a mistake to think of self-harm as often hidden – in my experience it may be selectively hidden, in that it may be concealed from parents, peers, partners or professionals, or the individual might self-injure on a part of their body that isn’t readily visible to others for a multitude of reasons. 

This definition also states that, ‘in the vast majority of cases, self-harm remains a secretive behaviour that can go on for a long time without being discovered’. The chances are then, that some of our clients may be self-harming and we don’t even know it. Whether they disclose or not is up to them, but I think it is also up to us. As with any subject that is remotely taboo, clients pick up on cues from us about what is ok to talk about. When I’m working with someone who presents with low mood or anxiety – which is almost every young person I work with – I always enquire about self-injury. Most tell me they are hurting themselves, or have done so at some point in the past. If you don’t ask the question, you might be sending a message that you are uncomfortable talking about it and therefore your client will be too, thus perpetuating the secrecy. 

When I asked, 12-year-old Gita told me that she had been self-harming since she was nine. I asked if she could tell me what she did, in as much detail as she felt comfortable to share. She was embarrassed and said she had never told or shown anyone before because she didn’t want to be accused of attention-seeking. I hear this lot. I said I didn’t need to see unless she wanted to show me, which she didn’t. She explained that she used the flat side of a scissor blade to graze the upper parts of her thighs. She had never broken the skin or caused bleeding. As we talked further, I began to understand that Gita had been struggling in silence with overwhelming emotional distress that she felt powerless to control. She was academically successful and popular at school, but had buried the pain of her parents’ separation and become isolated and depressed. Her mother was dealing with her own grief following the end of her marriage and the death of her father. Gita did not want to add to her mother’s distress or make her feel responsible for her unhappiness, and so she kept her feelings hidden. For some people who self-harm, the act of injury is what helps. Over time, we worked out that the important thing for Gita was not hurting herself physically per se, but having the power to stop the physical pain. Gita couldn't stop the emotional pain, but it helped her that she could stop the physical pain, and to be able to do that, she had to inflict it.

Gita was academically successful and popular at school, but had buried the pain of her parents’ separation and become isolated and depressed. Her mother was dealing with her own grief following the end of her marriage and the death of her father. Gita did not want to feel like she was adding to her mother’s distress or making her feel responsible for it and so she kept her feelings hidden. I meet so many girls like Gita who have concealed their psychological pain and the physical harm they have relied upon to manage it. They are the antithesis of the ‘attention-seeking’ adolescent.  I helped Gita to uncover the pain and put her feelings into words; a painful process, but with it came relief from no longer having to hide a secret that felt shameful and, in time, Gita no longer felt the need to rely on self-injury as a way of managing her emotions.


The NICE definition of self-harm includes: ‘... any act of self‑poisoning’4 and I think this inclusion is useful. I have worked with young people who self-poison by inhaling gas or aerosols or swallowing toxic substances. Their motivations are different from those of young people who take recreational drugs and it is important, therefore, to establish the meaning behind the act of self-poisoning – to cause harm or to get high – in the same way that it is important to distinguish alteration of the body from self-injury.

Robert was 14 and had just been excluded from school for the third time when he was referred to me for psychotherapy. He found it difficult to settle physically or mentally. His mother was emotionally distant, and was self-medicating for depression with alcohol. Robert had low self-worth and had internalised the script that he was ‘useless like his father’, who was serving a prison sentence for aggravated burglary. Robert was aggravated too, and had a tendency to aggravate people around him. Over six initial assessment sessions, I discovered that Robert had worked hard to keep his family narrative a secret and that he felt enormous shame when people found out. He had presented as angry and aggressive throughout primary school and had now turned that aggression on himself.  When I asked about self-injury, Robert told me he had, in the past, used aerosols to burn his skin. This started out as a dare but had developed into something more like self-punishment. He then began inhaling aerosols in order, he said, to ‘feel dead’. We began to understand this as a means of temporary escape: Robert didn’t want to die; he wanted some relief from the emotional pain of his experiences. Self-poisoning was a way to numb that pain by replacing it with another.  

Non-suicidal self-injury is not, and never has been, listed as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the guide developed in the US and routinely referred to by medical professionals throughout the UK. It is, however, included in a new category in the latest edition, DSM-56, called V-codes, which describe ‘other conditions or problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of a patient’s mental disorder’. (Of note, V-codes also include parent-child relational problems, relationship distress and academic/educational problems.) The new V-code categorisation explicitly recognises that NSSI (and other V-codes) are relational problems requiring relational solutions’, rather than mental disorders with the stigma this implies.While a primary function of inclusion in the DSM in the US is access to medical treatment, the new coding system provides a welcome shift away from medicalising behaviour and encourages professionals to think differently. 

DSM-5 defines NSSI as ‘the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, including behaviors [sic] such as cutting, burning, biting and scratching skin as a way of coping with difficult emotions’. This is the most inclusive of all the definitions I have found, as it addresses the what, how and why of self-harm, as well as what it is not. I think the ‘socially sanctioned’ part helps distinguish piercing, tattooing etcetera from self-harm, as does the NICE definition, and DSM-5 also highlights the distinction between self-harm and suicidal intent. Self-injury is often a means of staying alive, a bid for survival, not death, although it may be accompanied by suicidal thoughts and persistent self-harm can be a risk factor for suicide. 

Lucy was 13 and had a history of risky behaviour, including serious self-injury, sexual promiscuity and absconding when she was referred to me for psychotherapy. She was small, heavily made-up and fragile-looking. To me, she seemed empty inside, like a china doll. She said she hated her ‘no-good’ mother and described her father as a relentless bully who ‘doesn’t know when to stop.’ Shortly after we started to work together, her self-injury escalated. When her mother tried to make the home safe by removing any sharp implements, as I had insisted, Lucy smashed a window and used the glass to cut herself so deeply that she had to have stitches. She pierced her face with a compass point and the wound became infected. She refused to eat or wash. She dyed her hair blue. She had unprotected sex with older men ‘because they wanted to’. She constantly said she’d be better off dead, although she had no suicide plan or intention to kill herself. I wondered about the escalation in Lucy’s self-harm and what the attacks on her body might be about. I understood the uninhibited flaunting of her physical injuries as an attempt to draw attention to her distress. It felt important to show her that I understood that these visible displays were communicating pain that she was, as yet, unable to verbalise. I didn’t want her to perceive me as either intrusive father or useless mother; I needed to ‘hold’ Lucy (psychologically) and proceed at her pace. My being able to bear her behaviour allowed Lucy to finally disclose that her father was sexually abusing her. We later came to understand her attacks on her own body as symbolic attempts to eradicate the intolerable memories of the trauma she had endured. They might also have illustrated her attempt to control her feelings of murderous guilt and rage towards both her abusive father and her mother, who failed to protect her, by displacing them onto herself.8 My work with Lucy came to an abrupt end when she was removed from her family for her own safety. 


With Lucy, I had no reservation about sharing information with the statutory authorities about her self-harm and her disclosure of abuse. But it is rare that I need to raise self-harm as a safeguarding concern, even though most of my clients self-injure. When I contract with new clients, I tell them that, if I am worried about their safety I might need to talk to someone else about it, but that I will always talk to them first. If a client tells me they are self-harming, I keep in mind the DSM-5 definition – that the behaviour is ‘a way of coping with difficult emotions’, and that it is different from suicidal intent.I explore their means and motivation by asking what, how and how often they injure themselves. I tell them that it is not for me to either condemn or condone their behaviour, but that my role is to understand what they are doing and why, and to work with them, and their family if it’s appropriate, to keep them safe. I usually say that I have met lots of young people who self-harm, to demonstrate that I can bear it, but I always emphasise that I know it means something different for each of them. I tell them that I want to understand what it means for them, to reassure them that I am making no assumptions.

For me, risk assessment is not a one-off event; it is entrenched in every session of psychotherapy. It includes an appraisal of each client against what might be ordinary, age-appropriate behaviour within their family and social context. Assessment is also informed by organisational protocols and procedures and professional ethical guidelines, as well as by my own clinical experience and instinct. The NICE guideline on self-harm provides a helpful framework for working with clients safely. For clients who repeatedly self-harm, NICE recommends offering advice on how to treat their own superficial injuries and on harm-minimisation, for example by using clean blades and antiseptic products, rather than trying to stop them from doing it; which is seldom effective.4

In my work with both Dan and Robert, I understood their self-injury as an expression of distress rather than suicidal intent, and embedded in our sessions suggestions for ways they could self-harm more safely. With Gita, I didn’t share with the statutory authorities or with her family her disclosure of self-injury, despite her young age, but nor did I collude with her secrecy. I encouraged her mother to acknowledge and ‘bear’ her daughter’s feelings of grief as separate from her own. 

If we continue to monitor the level of risk, we should be able to hold our clients’ distress. Putting words to their pain, in my experience, leads to a reduction in the reliance on self-injury, whatever the client’s age.  


1. See

2. See

3. See

4. NICE. Self-harm. QS34. London: NICE; 2013.

5. Mental Health Foundation. A to Z: self-harm. London: Mental Health Foundation.

6. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edition) (DSM-5). Arlington, VA: APA; 2013.

7. Self-Injury Institute. The surprising place for self-injury in the new DSM-5. [Online.] Los Angeles, CA: Self-Injury Institute.

8. Fonagy P, Target M. Towards understanding violence: the use of the body and the role of the father. In: Perelberg RJ (ed). Psychoanalytic understanding of violence and suicide. London: Routledge; 1999 (pp51–72)

The T word

Published in bacp Children & Young People, December 2016

Jeanine Connor addresses difference in the form of sexuality and gender, including transgender, and invites us to work out how we will welcome all such diversity into our counselling rooms – by informing ourselves and by leaving behind any fearful or confused mentality around young LGBTQ clients that might lead us unwittingly to withdraw from them therapeutically 

The language of gender and sexuality

The acronym LGB (lesbian, gay, bisexual) first entered common parlance during the 1980s. Since then, it has been broadly accepted that sexuality cannot be reduced to homo- or hetero- sexual. Gender too is less likely than it once was to be defined in binary terms and LGB was extended a decade later to reflect this, incorporating T for transgender. The acronym has since been developed further to include Q, for queer or questioning, depending on who you ask, and sometimes + to incorporate asexual, pansexual, transsexual, intersexual, intergender and other sexual or gender identities excluded from the original abbreviation. There are some references on social media to LGBTTTQQIAA but that seems much too nonsensical for most of us to fathom, both inside and outside of the LGBT community. Suffice to say, the terminology can be a bit baffling, with the potential to plummet into political correctness pitfalls ever-present. If in doubt, I suggest sticking with the basic four or five letter acronyms (LGBT and/or LGBTQ). Confusion aside, this new language recognises difference and brings with it a level of acceptance. If people of various gender and sexual identities were not recognised, there would be no need for the appellations. But with everything so fluid, including sexuality and gender, how can we, as counselling professionals, ensure that we retain a firm footing and work candidly with young people who present with issues relating to their gender and sexuality?


I am on record as saying that sexuality is the biggest issue for adolescents and pre-adolescents and I maintain that its exploration takes up many a therapeutic hour. Sexuality is a broad church, incorporating questions about physical development and intercourse, intimacy and relationships, normalcy and perversions, gender, transgender and various sexualities. Younger children (7, 8, 9 year olds) bring questions about their bodies and other peoples’ bodies, as might be expected, but I also get asked about the factual stuff by mid/late teenagers, the age group that are presumed to know it all already. But how can they know if they have not had a thoughtful parent or parent figure to ask and reflect with and if their only points of reference are sneakily looked at porn and ill-informed playground banter?

Rethinking gender fluidity

Adolescents also bring issues around first sex, safe sex, pornographic sex and issues around sexuality and gender variance. The latter is a more recent addition to the list of ‘things to take to therapy’ and according to the Tavistock and Portman, there has been a doubling of referrals to their specialist Gender Identity Service (GIDS) which offers support to transgender and gender variant young people under the age of 18 (1). Many counsellors are struggling to comprehend this shift. A colleague was incredulous when his teenage client said he identified as gender-fluid. The counsellor thought this was a ridiculous statement and told me that gender cannot possibly be fluid; we are either male or female. I agree that gender fluidity can be a challenging concept, particularly when it jars with one’s own personal and perhaps religious beliefs, as in my colleague’s case. But I’ve met numerous adolescents who identify this way, or as transgender or gender variant, and in each case have explored what it means to them. I’ve shared some of my clinical experiences in this journal previously (2). My aim in the current article is to reflect upon the cultural shifts and theoretical models that are informing my work. Some psychologists have suggested that sex and gender should be conceptualised, not as switches that point this way or that, but instead as a series of adjustable dials. Thought about this way, sex is a continuum and gender a spectrum. Neither are either/ors. These theoretical dials affect both nature and nurture. They influence hormone levels and development in utero and at puberty, as well as personality traits, and social, historical and cultural factors (3). The dials not switches model supports the notion that gender identity is less likely to be entirely male or entirely female and more likely to be something in between; perhaps something more akin to gender fluidity. But my colleague’s explanation, the only one that fit with his own sensibilities, was that gender fluidity is the latest fad. While I disagree, I acknowledge that up until a few years ago gender issues rarely entered the therapy room. To put this into perspective, transgender and gender variance remains relatively uncommon. While referrals to GIDS have doubled, they still only account for 0.01% of the population. The average age of referral is fourteen and the service has witnessed an increase in referrals of natal females; i.e. young people assigned female at birth (1). So if it is not the latest fad, I wonder how we can explain the changing zeitgeist.  


Cultural influences

There is no doubt that the media plays a part in influencing the content of therapy. The lasting legacy of ‘erotic’ literature aimed at women, euphemistically described as ‘clit-lit’ has been more open discussions about bondage, domination and sadomasochism (BDSM), as well as choice, control and rape. Meanwhile, soap operas such as Hollyoaks, documentaries including Girls to Men and Transgender Kids, as well as discussions and dramatisations on Radio 4 have brought gender identity and gender reassignment into mainstream consciousness. Once these issues have been evoked and emotions conjured, young people have limited options about what to do with them. Many families feel embarrassed or ill equipped to discuss sex and gender identity with their children or they leave it too late, not through neglect, but through ignorance about what’s really on their minds. Formal sex and relationship education is sketchy at best with many teachers afraid to talk about sex with their students for fear of seeming provocative or encouraging illicit activity. I think it will be a long time before gender variance makes it onto the mainstream curriculum. But, like other apparent taboos, it has made it into the therapy room already. Some young people perceive their therapist as their only reliable source of information and for them counselling provides a safe space for questioning and exploring issues to do with sexuality and gender identity. Others are less fortunate.  Numerous professionals tell me that their clients never talk about sex or gender, which conveys more about the counsellors’ lack of preparedness than their clients’ issues. I am in no doubt that young people pick up on adults’ discomfort and censor what they share, repressing their thoughts and ending up feeling more shameful than they did before.    

Levels of engagement

In my experience of working with young people, in various settings over two decades, sex and sexuality have remained top of their most talked about list. My clinical experience suggests that merely adopting a stance of unconditional positive regard doesn’t cut the mustard. Young people want to experience a connection and often that involves provoking a reaction. I can recall one particularly revealing session with a sixteen-year-old girl who described to me her fantastical carnal exploits in graphic detail. She identified as gender fluid and pansexual meaning, she said, that her identity and sexual attractions were not determined by biological gender. I listened quietly and nodded attentively as she became increasingly animated. I didn’t question or comment. I tried not to judge, challenge or condemn. My experience was limited in this arena and I did what I thought a good therapist should do; I adopted a neutral expression and said nothing until eventually she yelled at me to ‘stop fucking nodding.’ That client taught me, with a verbal slap in the face, that it takes two to tango, to fuck and to engage in therapy. People tell me they are intimidated by adolescents and are afraid to talk to them about sex. I can see why. Adolescents are overwhelmed by intimidating feelings, frequently to do with their sexuality, and sometimes those feelings spill out.

The legacy of MoU

Our society has thankfully progressed from a time when homosexuality was perceived as illegal, taboo and/or a psychiatric condition in need of cure by medical intervention or talking therapy. It seems we are a bit behind in our attitude towards gender variance. The Memorandum of Understanding (MoU) in relation to working with sexual diversity was signed by the British Association for Counselling and Psychotherapy (BACP) in January 2015. The organisation also lent its official support to the Royal College of Psychiatrists declaration on sexual orientation which states that the diversity of human sexualities is compatible with normal mental health and social adjustment (4). In addition, BACP states that it opposes any psychological treatment such as reparative or conversion therapy … based on the premise that the client/patient should change his/her sexuality (5). However, BACP heard that the MoU was counter-productive to many counselling professionals, who became anxious that providing therapy to clients with gender and sexuality issues might be perceived as attempts at conversion. I frequently hear evidence of prevailing anxiety from professionals who are fearful of taking on transgender clients. I had a long debate with someone recently who told me that his biggest fear was that a client would opt for gender reassignment surgery as a result of counselling. His fear was not that he would be accused of attempts at conversion or reparation, but instead appeared to be that he might actively promote transgender. The counsellor’s fear is based on ignorance; a very small number of transgender people opt for surgical reassignment, with or without counselling. It surprises me that colleagues are able to manage the risk and uncertainty surrounding clients who have eating disorders, deliberately self-harm or contemplate suicide, where the worst case scenario is loss of life, yet they feel overwhelmed by transgender. Are they responding to fear of the unknown, or is the potential of transgender perceived as a fate worse than death?  

I cannot know how counsellors and psychotherapists managed their anxiety prior to the MoU in 2015, but I can assume there was a heavy dose of denial and avoidance. However, once acknowledged, BACP’s response was to commission an article about how counsellors and psychotherapists work with LGBTQ (Q for questioning in this instance). The results were published in an article titled ‘I think I’m gay… can you help?’(6). My own interview for the piece provoked thoughts about my work with transgender and highlighted the lack of specialist training. The article was well researched and covered a wide range of experiences of working with sexuality, but it felt like a hark back to 1980s LGB. The T word was conspicuously noticeable by its absence.  


We will inform ourselves

So where does all this leave those of us who are keen to develop our learning and welcome all sexualities and genders into our counselling rooms? It leaves some fearful and avoidant and many confused. As a profession, we are doing a disservice to clients (or potential clients) who identify as transgender, gender variant or questioning. While some of us are keen to learn, it is unethical to rely on our clients to teach us (7). We have to be proactive. We have to seek out knowledge and education from reliable sources and make referrals to specialist services. GIDS is stretched. Currently there are just two clinics in the entire country; one in London, the other in Leeds. They offer assessment and treatment to young people under 18. Some assessments lead to a formal diagnosis of gender dysphoria, where identified gender is contrary to gender at birth, but most do not. It is interesting to note the change in diagnostic label in DSM-V from gender identity disorder to gender dysphoria (8).  Its continued inclusion in the diagnostic manual is, in part, to facilitate access to medical intervention. In the USA, treatment requires insurance, which requires diagnosis. In the UK too, private and public health care providers often rely on a diagnosis to inform an appropriate care pathway. The newer diagnostic label also aims to alleviate the implication of ‘disorder’ and is therefore less stigmatising and more accepting, rather like the extended acronym LGBTQ.


Where appropriate, GIDS can offer an endocrinological assessment to explore hormonal and chromosomal characteristics. In some cases they can prescribe hormone blockers to delay the onset of puberty. This is a fully reversible medical intervention which affords the young person time to explore their gender identity without experiencing the physiological changes associated with puberty, which for gender variant or questioning young people can be intolerable. However, GIDS stress that family and early developmental experiences are significant contributing factors and that adult gender identity has its roots in early childhood (1). The primary aim of the service is to explore family relationships and ease emotional, behavioural and relational difficulties.  The team offers professional consultations, individual and family psychotherapy, parent groups and groups for young people, often alongside local specialist Child and Adolescent Mental Health Services (CAMHS). In other words, much of what they do is what we all do in our work every day – assess, explore, support and reflect, by offering therapeutic interventions to children and young people alongside direct or indirect work with the family. This is what counsellors and psychotherapists are equipped to do and is what we do well. So there is nothing to be afraid of.


Our world is ever evolving. Young people are exposed and have easy access to more varied and more extreme social influences. They are bombarded with images 24/7 dictating how they should look, feel, behave and have sex. They are under constant scrutiny. They grow up fast and display signs of physical development younger than ever before. Onset of puberty has decreased with many girls showing first signs of sexual development at eight. Numerous theories have been posited for this including diverse factors such as nutrition, pollution, the absence or presence of fathers, increased affluence and over-exposure to television (9). Meanwhile, experienced counsellors and psychotherapists in young people’s services are an ageing population and many are out of touch. When I mentioned this article to a colleague he had no idea what LGBT meant. This unawareness is astounding, but not uncommon. Our own adolescence was poles apart. Homosexuality was not decriminalised until 1967. The age of homosexual consent only lowered to sixteen in 2001. For us, sexual development happened later. There was no Internet, no same-sex marriage and no awareness of gender variance. I’ve said it before but will keep banging the same drum; we owe it to the younger generation to keep up. We must inform ourselves (10).


1.    Gender Identity Development Service, 2016, Tavistock and Portman NHS Foundation Trust. London

2.   Reflecting on…Transgender, 2016, Counselling Children and Young People

3.   Pirlott, A. G. and Schmitt, D. P., 2014, Gendered sexual cultures in Culture reexamined: Broadening our understanding of social and evolutionary forces, Washington, DC: American Psychological Association

4.   Royal College of Psychiatrists, 2014, Statement on sexual orientation. London

5.    BACP, 2013, Ethical framework for good practice in counselling and psychotherapy

6.   Therapy Today, February 2016, I think I’m gay…can you help?  

7.   BACP, 2016, Ethical framework for good practice in counselling and psychotherapy

8.   Diagnostic and Statistical Manual of Mental Disorders (DSM-V), 2013, American Psychiatric Association

9.   BBC News, 2015,

10.                  Therapy Today, July 2016, Keeping up with our clients

Keeping up with our clients: a response to the new ethical guidelines

Published in bacp Therapy Today, July 2016

‘My foremost aim is to promote the client’s wellbeing and protect them from harm. For me, these are the guiding principles of my work and for my clients that is good-enough’

When was the last time you read the BACP Ethical Framework? In my experience, formal documents such as these are read on a need to know basis; something goes wrong, or has the potential to go wrong, and members turn to an official lodestone for succour. According to Andrew Reeves, BACP Chair, the revision of the Ethical Framework is in part a response to ‘scandals and service failures in health and social care that have inflicted significant harm’. So it too could be described as a reaction to things gone wrong, or an attempt at reparation, or an effort to develop our learning within the wider social and political context, and an endeavour to ensure that things go less wrong in the future.

‘Our commitments to clients’ serve as a reminder that our overarching aim is to do good, not harm, and there are some interesting amendments. Previously, we were committed to ‘alleviating personal distress and suffering’ whereas now we are committed to alleviating the ‘symptoms of’ personal distress and suffering. I facilitated a training day about mental health and asked participants to respond to the statement ‘I see it as my role to cure my client’s symptoms’. The unanimous consensus amongst the forty BACP registered counsellors was a shared discomfort with the words ‘cure’ and ‘symptoms’, both of which were initially perceived as pathologising. But there was motive to my mischief. As I encouraged further consideration of the statement in small groups, I witnessed a gradual shift in perspective. Most counsellors remained uncomfortable with ‘cure’ which developed into something more like ‘alleviate’. As their explorations continued, I observed less abstract thinking and a greater reflection on tangible clinical experience. One counsellor spoke about a client he’d been working with for many months who had presented for counselling with chronic anxiety and social phobia. He had been unable to maintain a personal relationship or hold down a job for most of his adult life and had fallen into a state of depression following the death of both parents. The counsellor admitted an initial urge to make things better for his client; a desire to cure him. On reflection, he acknowledged the fact that while he could never hope to relieve his client’s pain and suffering completely, he had noticed a lessening of the symptoms that initially brought him to counselling. With the support of the group, he was able to reflect on the work, which up until now, had felt hopeless, and reframe the counselling objectives. As a result, he would return to the counselling room with an increased robustness that would feel enabling for his client. The exercise had achieved its aim of bringing alive our commitment to alleviate the symptoms of distress and suffering in an authentic and meaningful way. If time had allowed, it would have been pertinent to replicate this application for each of the commitments outlined in the ethical framework. This would be valuable CPD.

The new framework states that well-founded ethical decisions should be strongly supported by one or more of six ethical principles; trustworthy, autonomous, beneficent, non-maleficent, just and self-respecting. In my experience, the most difficult dilemmas arise when there is an impasse between two or more of these principles. A common example from work with young people is of requests for information. Parents and guardians are commonly asked to provide pre-emptive consent for professionals to share information about their children’s development, education, health and social care. What this means is that an adult with parental responsibility may have consented to information sharing when their child first accessed a service. In reality, this might have been some considerable time prior to the current involvement and/or may have been contrary to the child’s own wishes. Medical professionals, including counsellors and psychotherapists, should also seek consent from the young person themselves according to the law of Gillick competence, therefore valuing the individual’s right to be autonomous and self-governing. A difficult ethical dilemma can arise when consent has been provided yet the counsellor believes that to share information would be contrary to promoting the client’s well-being. It seems to me that whether the information was shared or not, the counsellor could argue that he or she had made a decision that was supported by one or more of the BACP’s ethical principles. Yet the impact on the client of sharing or not sharing information would differ enormously. When ethical dilemmas such as these arise, as they so often do, my foremost aim is to promote the clients’ wellbeing and protect them from harm. For me, these are the guiding principles of my work and for my clients that is good-enough.    

Where the previous BACP framework contained ten personal moral qualities to which we were ‘strongly encouraged to aspire’, now there are eleven. Some have been left out (competence and fairness) while others have been added (care, diligence and identity). I think they are all worth considering, both individually and jointly in supervision. They provide a solid framework within which clinical issues can be considered. For example, I have supported supervisees in considering how they can remain resilient in their practice without diminishing their own needs, how they can deal with colleagues honestly and how they can manage their fears and uncertainties in an often uncertain profession.

The Good Practice section of the new ethical framework has had a major overhaul and is clearer, more comprehensive and promotes greater inclusivity. We are no longer being told, in a somewhat detached way, what practitioners should do, but instead the statements read rather like a pledge: ‘We will work with our clients… We will do all that we reasonably can… We will collaborate with colleagues…’ This engenders a sense of ownership that should promote useful self-reflection. There were a couple of statements that stood out for me as particularly pertinent to my work with young people. For example; ‘We will…recognise when our knowledge of key aspects of our client’s background, identity or lifestyle is inadequate and take steps to inform ourselves from other sources where available and appropriate…’ (22f). I am forever being reminded of my inadequate knowledge about social media, gaming, popular music, sexual practices and its accompanying terminology, and I do my best to educate and inform myself. My Google search history makes for fascinating reading! For example, a young person recently told me about the pressure he felt under to maintain ‘streaks’ on Snapchat. I thought I knew what Snapchat was, but what I hadn’t known is that a year ago the social media forum introduced Snapstreak, which measures the number of days that you and a friend have been exchanging Snap by adding a flame and a number next to their name. If one person fails to respond the streak is broken, the flame dies and the number returns to zero. The pressure comes from the competitive element of building the longest streaks. So for the young person I spoke to, if he didn’t respond to every message immediately, he felt responsible for letting his friends down by destroying Snapstreaks built together over several months. Competition abounds in adolescents’ lives and these things matter because they influence their social identity. However, I continue to witness colleagues’ misperceptions about the inherent dangers of ‘new’ apps such as Facebook and Snapchat that, in their opinions, cause harm. Snapchat has been here for 5 years and Facebook has been around for twelve; it’s old news, as is the fact that many of the Association’s members remain uninterested and uninformed.

Another area where I have felt compelled to inform myself is in relation to physical illness. I have no formal medical training but have developed a decent understanding about conditions such as cerebral palsy and hypermobility syndrome, because I’ve worked with clients who have had these diagnoses and I needed to understand them. Similarly, I know about the effects and side effects of common drugs such as Risperidone, Sertraline, Quetiapine and Aripiprazole. And I can pronounce them! While working with a young man with testicular cancer I read lots about symptoms and treatments so I could better understand what he was going through. Being informed of the facts doesn’t replace getting to know what the condition feels like for the individual, that’s always idiosyncratic, but it does provide a shared language that helps us to connect.

My guess is that many people will interpret this clause of the Good Practice guidelines in a different way, perhaps focusing instead on culture, religion or, if we’re lucky, sexuality. At a recent professionals meeting we discussed a young person who identified as transgender and pansexual. Most were unfamiliar with the concepts. Some perceived them as ‘fads’. There was a conversation about gender identity and bisexuality being ‘all the rage’. I applaud the inclusion of the statement ‘we will… inform ourselves’. My fear is that those colleagues with the most to learn do not know what they do not know. I suppose it’s every other member’s responsibility to give them a gentle nudge.      

Another clause that stands out to me is ‘We will ensure that ‘reasonable care is taken to separate and maintain a distinction between our personal and professional presence on social media…’ (33c). In my experience, the worst offenders fall into one of two camps; they either use social media indiscriminately, blurring the boundaries between personal and professional – Newsflash: it’s not just young people who over-share – or they shy away from it completely. I was commended recently on my ‘media presence’ by a counselling training provider who had accessed my services via my professional website and who follows me on Twitter. She spoke about the widespread reluctance amongst counselling and psychotherapy professionals to make use of social media and her consequent difficulty in making contact with any. I’m aware of this reluctance. At a training I attended, one prominent facilitator proudly announced that he has no Internet presence whatsoever! How does he get work? I use Twitter to share pertinent reflections, links to my published work and newsworthy items from the world of counselling and psychotherapy. I follow professional organisations such as BACP and Therapy Today as well as a number of psychotherapists who I hold in high esteem. It’s a way of keeping in contact, preserving my professional profile and keeping my knowledge up to date; which is another of the professional standards outlined in the BACP Good Practice guide. My website includes details about my qualifications, experience and private practice. I’ve outlined my therapeutic model and included a contract and referral form; all in line with the BACP Ethical Framework. Rather than merely telling potential clients that I abide by the Association’s professional standards, I use my website to demonstrate how I do this. And I share nothing there or on Twitter that I wouldn’t share in the therapy room. The social media forums I access for personal use are separate and I’ve learnt to check the privacy settings regularly to maintain this. If clients request to ‘friend’ me on Facebook I remind them about the therapeutic boundaries that exist to protect us all, and that this applies to the virtual world as well.

If you haven’t already reviewed the new Ethical Framework then you should do it now. I also urge you to have a notebook and pen to hand. Better still, examine the document with a supervisor or colleague and initiate a dialogue. Don’t look at it as a dry, directive document. Instead, transform each clause into a question and reflect on how it applies to you and your clinical work. Really engage and be honest about your practice. Think about the times when something went wrong, or could have done, and use the framework to help you to consider how you would respond differently if a similar dilemma arose in your work tomorrow. The revised Ethical Framework won’t tell you what to do or alleviate your clinical responsibility, but it will provide you with a scaffold, just as any good framework should.

Where Lunatics Prosper

Published in bacp Children & Young People 2011, republished in Therapy Today

A growing number of young boys are being referred to CAMHS because they are unable to concentrate, failing academically and have no impulse control. Jeanine Connor argues that computer games are partly to blame for a marked increase in young male aggression and age-inappropriate sexual behaviour. 

The title of this piece is the tag-line from Grand Theft Auto (GTA) III (1), a console game marketed at young men aged eighteen and over. Regrettably, the appeal of this, and similar games, covers a much wider demographic and is the primary pursuit of many children as young as eight years old. One of the mainstays of this type of game is violence; injury and death is portrayed in graphic detail as dying bodies hurl through the air and bullets cut through flesh, splattering blood across the screen. The character in Call of Duty (2), for example, opens fire in a busy airport killing innocent bystanders in order to progress to the next level. I was informed of this by a boy of eleven who, reflecting on his hobby in a therapy session, told me; ‘I don’t know what I would do if I was ever in a real airport with a gun’. God forbid, I thought. The latest blockbuster in the Call of Duty series is Black Ops (3) which sold more than 7 million copies within 24 hours of going on sale. In this game, the marketing hype informs us, players are able to ‘turn down the blood and turn off the profanity to suit their needs’. There can be no argument that the amount of blood and profanity a child ‘needs’ is zero, yet the prepubescent boys who spend their free time playing these games seem most unlikely to censor them.  Equally as concerning is the sexual content of many console games played regularly by young children. In GTA III the character acts out sexually explicit scenes. In GTA IV (4) he picks up prostitutes and selects from three levels of service; masturbation, fellatio, and full sexual intercourse. Many of the boys who access these games are still in junior school and spend several hours a day playing them in bedrooms, behind closed doors, often with their parent’s knowledge and consent. I wonder if these parents would be as consenting to their young sons watching pornographic films.    


A recent study of ten and eleven year olds conducted by Bristol University found that playing computer games for more than two hours a day increases the risk of mental health problems by 60% (5). This is a scary statistic but, like most statistics, it does not really mean very much to most people. My own observation is that players of [most] console games are rewarded for action, speed and progressing to higher levels by fair means or foul [legal ‘cheats’ are readily available online]. I hear from countless parents and teachers about their children’s inability to concentrate, about their uncontrollability and about their academic failings. I wonder aloud about the link between their computer habits and observable behaviour. I also hear about children who are described as violent to siblings and peers, who use sexually explicit language and who seem devoid of empathy. I speak to children about their interests and learn that they enjoy games in which they are vicariously rewarded for killing and that the role of female characters is merely to provide visual and sexual gratification. 


I hear the argument touted vociferously that there is no direct link between the playing of console games and violent behaviour, but my clinical experience highlights numerous risk factors. As with most experiences, context is paramount. Many of the children I work with have grown up in families where boundaries are, at best, permeable. Many have witnessed aggression and violence and have experienced trauma, neglect and abuse of all kinds. These children are twice as likely as those who are not deprived or disadvantaged to develop a formal mental illness. In order to escape their despicable realities, many of the children I meet in the consulting room have retreated into a fantasy world of console games. In doing so, they form identifications with fantasy characters who are fighters, killers and abusers, in order to defend against their own vulnerability. With a gun in their (virtual) hand and a (virtual) female companion to provide sexual gratification at the push of a button, these children can, at last, feel truly omnipotent.           


Child and Adolescent Mental Health Services (CAMHS) are receiving a growing number of referrals of violent and aggressive boys who are unable to concentrate, are failing academically and have no impulse control. In many cases, the referrer is seeking a diagnosis of and treatment for Attention Deficit Hyperactivity Disorder (ADHD). A similar, yet distinct, type of referral relates to children who are described as destructive, aggressive, and lacking in empathy, obsessional, hyper-vigilant and overly-sensitive. The referrer in these instances is often seeking a diagnosis of Autistic Spectrum Disorder (ASD).  In both types of referral, a mental health diagnosis is sought in order to explain the child’s behaviour and, in many cases, a drug to control it. And I can see why. These children present with the clinical symptoms learned by professionals by rote from diagnostic screening tools and manuals such as DSM-IV (6) or looked up on the Internet by baffled parents. I recognise and support the merits of thoughtful, accurate diagnosis and treatment, but to label a child in haste is tantamount to imposing one’s own version of reality onto an already identity-confused individual. To do so is, in effect, saying ‘I shall view you and define you in this particular way and completely ignore your own experience of who and what you are.’ (7). It is also worth noting that Fetal Alcohol Syndrome, a widely under-diagnosed condition, looks very much like ADHD and in some cases ASD. In my opinion, any mental health assessment is incomplete if we ignore the child’s family and environmental experiences. To do so may result in a neat diagnosis, but it is also likely to leave the child exposed to further risk and potentially irreversible damage. 


I am lucky, as are the children whom I assess, in that I work as part of a multi-disciplinary team of mental health professionals. During thorough assessment, we have noticed remarkable similarities in the family backgrounds and experiences of the children I have begun to think of as ADHD-like and ASD-like. The majority of ADHD-like children we meet, predominantly latency aged boys, have witnessed domestic abuse and been allowed to play age-inappropriate console games. The same is true in many of the ASD-like children referred to our service. This suggestion is not the result of subjective, self-serving research; it is a clinical observation which has presented over time from the ordinary case-load of referrals made to an ordinary CAMHS service. My guess is that similar observations are being made in clinics up and down the UK.  


What follows is a clinical case study which is an amalgamation of dozens of children I have assessed for therapy. It is presented as an amalgamation for two reasons; to maintain the anonymity of the children detailed and because their stories are so similar. Darnell is a nine year old boy referred to CAMHS for a mental health assessment by his GP. The referral letter states that Darnell meets every one of the criteria for ADHD and is so extreme in his presentation that a diagnosis is inevitable. Darnell is described as hyperactive and inattentive. He is alleged to bully his peers, particularly girls, with sexualised language and aggression. He cannot be left unattended with his younger sister, Jess who is four. He is failing academically and has been suspended from school on numerous occasions and faces permanent exclusion if his behaviour cannot be tamed.


At assessment, we met with Darnell, his mother and Jess. Mum was heavily pregnant and showing signs of bruising to her face. We were told that Darnell is uncontrollable and that he refuses to do as he is told; telling his mother he hates her and that she should ‘fuck off’ and is ‘a slag’. He has said that he wants to kill her and also that he wants to die. Darnell’s mother confided that ‘he has always been like this’ and that even as a baby he was ‘difficult’, whereas Jess is, and was, much easier. Jess did indeed remain calm and unusually quiet throughout the two hour assessment. Darnell sneered and groaned. He broke some of the toys and devoured a packet of tissues by chewing them up and spitting them out. We learnt that Darnell was an unplanned baby. His mother was eighteen and had been in a relationship with John, Darnell’s father, for only a few months when she discovered she was pregnant. We wondered if John had been supportive and were told that ‘he did what he could’ but that they lived separately with their own parents for most of the pregnancy until they moved into Social Services funded accommodation prior to Darnell’s birth. His mother told us that John drank a lot ‘because of stress’ and would sometimes become aggressive. He once punched her in the stomach when she was pregnant and she gave birth with a black eye. She believed that John loved her and wanted their baby. Following Darnell’s birth, the violence ‘got really bad’. The relationship ended when John drove their car, under the influence of drink and drugs and with baby Darnell and his mother as passengers, under a truck. She thought they would all die. John went to prison for ‘driving under the influence’ but she thought it was important to maintain contact between Darnell and his father and so regularly took him for prison visits in his early years.  


Darnell’s mother began a relationship with John’s friend, Jason, who ‘was really supportive at first’ while John was in prison. But he raped her and she became pregnant with Jess, telling no-one the details of the conception. She has been in her current relationship with Jamie for eight months and he is the father of her unborn child. Jamie was described as ‘like a third child’ and Darnell’s mother admitted that they have heated arguments and sometimes ‘use each other as punch bags’ to ‘let off steam’. When I spoke to Darnell alone he told me that he hates Jamie because he is mean to his mum and he is lazy and won’t play football. Darnell has learnt that if he is naughty at school he gets to go home and that way he can make sure his mum is ok. Yesterday the Police came again because Jamie had hit his mum because he thinks the baby is not his. Darnell said he tried to be good because he is frightened he will be taken into care like his older brother, a child I had not been aware existed, but who I later learnt was in foster care due to emotional and physical neglect. I expressed my concern about Darnell’s situation, stating very clearly that it is not ok for grown-ups to hurt each other or to make children feel frightened. Darnell admitted that he sometimes feels sad, but ‘not frightened because I’m not gay!’ I asked Darnell what he likes to do when he isn’t at school and was given the inevitable response of ‘x-box’. Fearing the answer, I asked Darnell which games he likes to play. I noticed him become excited and animated for the first time during the assessment. He said he likes the GTA and COD games and had just got Black Ops for his ninth birthday. I commented on how lively his expressions had become and wondered aloud what it was that Darnell enjoyed about these games. He said simply, ‘sex and killing’.


‘Darnell’ is illustrative of countless young boys whose lives consist of real and virtual violence and who often present as ADHD-like. Their lives are messy, unsafe and without boundaries and so it should be no surprise that they present as chaotic, at risk and uncontrollable. These children ‘create havoc at home and school... as if they were spilling out all over the place’ (8). Children like Jess are also damaged by their experiences and remain at risk but, unlike Darnell, many of them go unnoticed. These children are compliant and expend their energy ensuring that there is no mess and no chaos as an antithesis to their messy and chaotic lives. They are often hyper-vigilant to noise and notice everything. As they get older they may switch off emotionally and end up in GP surgeries and CAMHS clinics presenting as ASD-like.      


Children are damaged beyond measure by exposure to violent and sexual imagery and language; be it in the home or on the screen. Adults who allow this to happen are guilty of social and emotional neglect, or what has recently been termed ‘urban neglect through technology’ (8). Psychodynamic literature emphasises the importance of infant-caregiver attachment, yet for many children, early ‘care’ is provided by a screen portraying sex and violence. For many children, this provides a mirror to their external lives so that fantasy and reality become inextricably tangled. In the absence of a suitable father role model, the process of identity formation for pre-pubescent and adolescent boys becomes enmeshed with on-screen characters who are an exaggerated version of themselves (9). These boys crave ‘raw, loud and angry... because they need it to be strong enough to match and master their [own] anxiety and anger (10).


However, society is, on the whole, turning a collective blind-eye. Instead, the media spotlight highlights the potential impact of provocative clothing for young girls which, it is argued, leads to their premature sexualisation. Yet the spotlight has merely flashed over their male counterparts who, while their female peers play dress-up, are simulating oral sex and bloody violence. If this trend continues, trials for murder, rape, paedophilia and domestic abuse are more likely to draw attention to female attire than male console game addiction. This feared future will indeed be a place ‘where lunatics prosper’ (1).   



1. Grand Theft Auto III (2001) Rockstar Games, New York 

2. Call of Duty (2003) Activision, California 

3. Black Ops (2010) Activision, California

4. Grand Theft Auto IV (2008) Rockstar Games, New York

5. Bristol University study conducted by Dr A. Page et. al (2010) 

6. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (2000) American Psychiatric Association

7. Mollon, P. (2001) Releasing the self: The healing legacy of Heinz Kohut, Whurr, London 

8. Jennings, S. (2011) Healthy attachments and neuro-dramatic-play, Jessica Kingsley Publishers, London  

9. Taransaud, D. (2011) You think I’m evil, Worth Publishing, London 

10. Jones, G. (2002) Killing monsters: Why children need fantasy, super-heroes and make-believe violence, Basic Books, New York

Lies all Lies

Published in bacp Children & Young People 2011 

In this article I aim to address three key questions that have been recently in my mind, which are: 1. What are adults choosing to ignore when they deem something a child tells them to be a lie? 2. What are children trying to tell us when they tell us a lie? 3. How can psychodynamically informed thinking help us to reflect upon the meaning of children’s so-called lies?
A theme has developed in my psychodynamic practice with children and adolescents; that I am frequently ‘reminded’ by parents, carers, teachers and social workers that what my young patients have told me is a lie. These children have been accused (outside of therapy) of ‘making it up’ or of ‘attention-seeking’ and I have been assigned the wholly inappropriate task of getting them to stop. The baseline for my thinking about this is that children need us to hear what they say. Furthermore, they need us to help them to think about, rather than punish, nullify or prohibit, all forms of communication if they are to find the courage to speak to us. I think this is true whoever a child confides in, be it therapist, teacher or parent. It is a uniquely valuable experience to be thought about and thought with in the absence of judgement or bias; an experience which, of course, is fundamental to therapy. But I believe that any adult, whether in a professional or parental role, can enhance the channels of communication with the young people in their care by taking on board some of what psychodynamic thinking has taught us.  
Fantasy – v – lies  
Our aim in working with young people psychodynamically is to help them to unravel the many and varied realities they bring to therapy. These realities have both physical and psychological manifestations and they are carried consciously and unconsciously into the therapeutic space. My use of the term realities is intentional as I would argue that ‘lies’, in the traditional sense, never exist in the therapy room. My patients know, perhaps unconsciously, that I am not an arbiter of the truth (although I am often a detective!) and I think that this allows them the freedom to express their real and fantasised experiences and to explore them with a mindful ‘other’. Therapists might think about patient’s fantasies, or unconscious phantasies as Melanie Klein (1) called them, but in my view these are quite distinct from lies. I think that fantasies are similar to dreams in that they allow latent desires, fears and anxieties to become manifest in a more manageable form. Play, drawing and creative writing are used by children to express themselves in a way which words sometimes fail to do. These are more tangible vehicles for carrying unconscious fantasies into the realm of conscious awareness and they are valuable forms of communication about internal worlds. Many adults realise this, mostly at an unconscious level, but I think that this awareness can be used as a basis for thinking about so-called ‘lies’. For example, it would be extremely unlikely, even in the non-therapeutic world, for a young person recounting their dream to be branded a liar or for a child’s painting to be labelled a lie. If we think about children’s fantasies in the same way as we think about their other forms of unconscious communication it seems just as ludicrous, I hope, to judge them as lies. Just as the child’s drawing or dream symbolises and communicates something about their internal world, the young person’s narrative must also contain a form or fragment of reality which originates in real, rather than imagined, experience. For that reason it deserves to be listened to, accepted and thought about rather than labelled a lie.  
Reality – v – lies  
In my experience, what has been branded a lie often contains elements of current or historical abuse. In these circumstances the obvious hypothesis seems to be that doubt is a more comfortable position for the disbelieving adult to take up than belief in the unbearable-ness of child abuse. Furthermore, in deciding that a child’s allegation of abuse is a lie, the adult (or system) can avoid thinking about it further because in their mind it did not happen. This is a classic illustration of denial as a form of ego defence. I would also suggest that denying the abuse is a way that adults avoid becoming enmeshed in it themselves. The varied ways in which unconscious anxieties and defences can get played out in disbelieving adults is illustrated by three vignettes taken from my clinical work with young people. 
A seventeen year old female patient, who I will call Yolanda, made an allegation of rape against a male peer at college. The boy denied it and was believed by both sets of parents, staff and the police. He was a ‘good student’ while Yolanda was labelled a ‘drama queen’. By believing the ‘good’ boy, the system maintained an effective split between bad/abuse and good/non-abuse and positioned itself with the latter. No further action was taken and, more significantly I think, the awfulness of peer sexual abuse was eradicated from the minds of the system. However, Yolanda continued to suffer terrifying flashbacks of the rape in her nightmares and at college where, unsurprisingly, her behaviour became more unmanageable until she was excluded. In my view, her removal from college is a further illustration of an attempt to split off the ‘bad’ parts believed to be located in her (abuse and lies) in order to protect the ‘good’ institution. An alternative hypothesis is that her exclusion could be seen as a re-enactment whereby the system unconsciously identifies with the abuser and therefore prolongs, highlights and draws attention to Yolanda’s suffering. 
As Yolanda’s therapist, I had to bear in mind all of the ‘realities’ being revealed to me by my patient and the wider system. Notably, my responsibility was not to get to the truth but to bear witness to whatever my patient brought to her sessions, consciously and unconsciously, in the form of dreams, memories or lived experiences. Maintaining my position alongside rather than being drawn in was not easy but it afforded me the emotional distance and perspective my patient needed. Alice Miller (2) suggests that a therapist should ‘devote his full attention as a spectator to the drama, without jumping onto the stage and joining in the act’. It was the experience of a thoughtful and attentive ‘spectator’, I think, that enabled Yolanda to become aware of historical sexual abuse memories which were awakened by her recent experience. Clinical research (3) supports the hypothesis that memory for historical trauma can become entangled with memories for recent trauma. Yolanda’s childhood sexual abuse was brought gradually into conscious awareness and worked through in therapy until she was ready to make a full disclosure. Without the experience of having someone believe her experiences, the repressed memories of what happened to Yolanda as a child are likely to have continued to haunt her into adulthood. 
An alternative reality 
Also pertinent was the shift in attitude of the professional system during my work with Yolanda. At the outset, the preoccupation was with the ‘lies’ about the rape and how best to manage (i.e. change) Yolanda’s behaviour. In multi-agency meetings I was able to feedback into the system my observations of Yolanda’s emerging depression as well as her ambivalence about coming to terms with her experiences. While respecting confidentiality, I shared the idea that creating and/or maintaining difficulties in the present can provide a focus for feelings which belong in the past. I was able to share my thinking, at a theoretical level, that memories of historical trauma can become entangled with those of recent experience, and that therapy can help to untangle and make sense of this. By sharing my thoughts in this way, the confidentiality of Yolanda’s therapy was maintained and the system gradually became more reflective. We wondered together about what the ‘rape’ might represent for Yolanda which encouraged thoughtful rather than spontaneous responses. Eventually, a collective realisation was reached that what mattered more than the truth of the external reality was an acknowledgement of Yolanda’s internal reality. This insight raised awareness about the unbearable-ness of Yolanda’s experience in the here-and-now and enabled the system to reflect upon it as something real. The shift from arbiter of truth to thoughtful spectator was communicated unconsciously and, I believe, was fundamental to Yolanda’s subsequent disclosure of historical abuse; which, interestingly, was believed unanimously.  
 The disbelieving child
The second vignette contains an example of a different kind of ‘lie’; one which appears to symbolise the disbelieving part of the child located within a disbelieving system. Morrie was a fourteen-year-old boy who had been taken into care aged four after enduring incestuous sexual abuse. We had been working together for a year when his foster-carer found a note, written by Morrie, claiming that a same aged boy had forced him to perform oral sex. No-one in the professional system believed this was true and I was warned by his social worker that ‘while he might have the face of an angel, he lies like the devil’.  As with Yolanda, I was informed about the incident so that I could ‘address the lying’. 
One of the worrying things about Morrie’s experience was the inability of the system to think about it. Social services disbelieved him; the police colluded and dismissed his allegation; school excluded him (to ‘protect [the other boy] from further untrue accusations’) and his carers went on holiday leaving him in respite care for a week following discovery of the note. The message being communicated to Morrie was that he was a liar, the bad one, the ‘devil’ child and that nobody wanted to listen to him. Paramount in my mind was Morrie’s unresolved childhood abuse and how it might fit with his current experience. I was mindful that history might be repeating itself in more ways than one; that Morrie could have suffered further abuse and that, in the very least, he was re-experiencing disbelief and rejection from the adults responsible for his care. Evidence for the possibility of re-enactment was also present in the system, illustrated by a teacher’s flippant remark that Morrie was ‘once a victim, always a victim’ suggesting that, at least unconsciously, she believed that Morrie had experienced further abuse. 
It seemed vital for me to provide Morrie with a space to think alongside a thinking other. The next time we met he demonstrated his availability for symbolic thinking, quite beautifully, in the sand tray. The sand was damp and had formed lumps which Morrie crumbled between his fingers. He asked me to help ‘breakdown the hard bits’ and offered me a spade so as not to get my hands dirty. I commented that he seemed to want my help but also that he had a desire to protect me from the hard and disgusting bits.  In his own time and without prompting he told me that he had been ‘forced to do something’ and in lieu of naming the sex act he gagged and told me it had made him feel sick. He said he wanted it to stay a secret because thinking about it made him want to vomit. I think this feeling was mirrored in the system which was unable to acknowledge something as sickening as forced homosexual activity. 
Morrie told me he had coped with what happened by pushing it to the side of his head ‘where the bad stuff is’ so that he could just know about the ‘good stuff’. He could not elaborate but I noticed that one half of the sand tray now contained only fine sand without lumps and I commented that the ‘hard bits’ and ‘bad stuff’ had been separated to the other side. Morrie said this was what it was like inside his head but that we would not be able to get rid of it all today. Morrie’s sand play provided a concrete illustration of his attempt to split off the trauma as well as, perhaps, the system’s attempt to deny it. It also seemed to flag up the other ‘bad stuff’ which Morrie was unable to consciously acknowledge. 
In our work together, neither the historical sexual abuse nor Morrie’s recent experience was named and his motives and realities were never questioned. Instead, a containing space was provided in which he could play and communicate in ways which felt bearable, which I facilitated, encouraged and cautiously interpreted. What I witnessed was what Winnicott (4) described as the ‘space between inner world and outer reality [which] creates the possibility for playing and for the filling of the space with symbols’. In contrast, the wider system of school, social services and fostering, remained fixed in the belief that Morrie was lying. They questioned him repeatedly and when he was unable to recall specific details they called him a liar. They interpreted his anxiety, doubt and confusion as confirmation that he could not be trusted. In contrast to the professional network around Yolanda, this system refused to engage in any meaningful thinking about Morrie’s experiences with me or with him. My wondering about the timing of the disclosure, in context of the imminent anniversary of his removal from abusive birth parents, was dismissed as coincidence. My suggestion that Morrie’s depiction of oral sex with a peer was likely to contain at least some reality and that his normal adolescent sexual development was certain to be tainted by his early sexually abusive experiences fell on deaf ears. 
Evidence suggests that motivation to remember is a key component in memory and that in ‘a sexual or physical abuse situation, neither the situation itself nor the adult involved would encourage the motivation to remember’ (5). Further clinical research suggests that doubt and confusion is evidence of attempts to recall a true memory rather than of inventing a lie (6). The system rejected all my attempts to help them to think in this way and, like Morrie, I was ignored and dismissed. As concerning (and frustrating) as this experience was, it was also a powerful re-enactment of an abusive system which repeated and perpetuated Morrie’s experience of being abused. 
The overt lie 
The final vignette provides an illustration of a child who, in contrast to the first two examples, told lies which were obvious and easily falsifiable. Harry was referred for psychotherapy aged ten following concerns about his behaviour at home and school in the context of possible child protection. He disclosed that his mother was seriously ill with an incurable disease that caused her to lapse in and out of coma. His father did not allow him to visit her in the hospital which he was finding incredibly distressing, particularly as her birthday was approaching and he wanted to take her some flowers. Harry’s narrative was elaborate and included specific details about his mother’s illness, the hospital and the staff caring for her. He said that she became ill when he was five years old, just after the birth of his sister. Harry remembers there being lots of arguments between his parents and that occasionally these became violent. Soon after this his mother was diagnosed with terminal cancer and spent time in and out of hospital so that he rarely saw her. 
Taken at face value, Harry’s story is a sophisticated and somewhat disturbing lie. However, it is also a powerful communication about his experience of life and family relationships. It states undoubtedly that things changed for Harry when he was five years old. It is known from the history that this coincided with the two most significant events in his short life; starting school and the birth of his sibling. Thought about in this context, Harry’s claim that his mother was diagnosed with a terminal disease illustrates his overwhelming sense that he had lost her and that she would be gone forever. It is true that Harry’s mother went into hospital when he was five; to give birth to his sister. This knowledge is likely to have been very frightening for little Harry, particularly if his father, as Harry claims, did not allow him to visit her. We can imagine how confusing it can be for children to reconcile their idea of hospitals as places where the sick go to get better, with the notion that people go there to collect babies in order to usurp older siblings! Harry’s internal world seems to have become a tangle of hospitals, illness, babies and loss. His claim that his mother contracted an ‘incurable disease’ and slipped ‘in and out of coma’ seems symbolic of his internal reality. If, as hypothesised,  his mother’s ‘disease’ represents pregnancy, then attending to her baby could be experienced by Harry as an abandonment so catastrophic it feels as if she were dead to him, that is ‘in and out of coma’. 
Psychodynamic theory tells us that, at some level, even very young children associate pregnancy and birth with the primal scene and that this is often experienced as aggressive and frightening. Harry recalls violent arguments between his parents and perhaps associates this with the sexual act which produced the baby. From an Oedipal perspective, Harry may feel some sense of responsibility, hence his childish attempts at reparation in the giving of flowers. However, it is Harry’s father who is vilified; he is responsible for the arrival of baby, for making his mother ill and ultimately for standing between Harry and his mother. It was possible, over time, for Harry to work through his overwhelming feelings of love, hate and rejection in therapy. His emotional responses were undoubtedly real, his narrative was simply a vehicle used to carry them into conscious awareness.      
The three young people described in this article had all been accused of telling lies. What I discovered in working with them was that they were confused, frightened and traumatised; that they had something important to communicate; and that they needed the opportunity to think alongside a mindful spectator. Meeting them has been a privilege. I hope that their experiences will encourage professionals to employ a more psychodynamically informed way of thinking about young people’s communications and avoid at all costs the temptation to dismiss them as lies. 
1. Klein, M. (1955) The psycho-analytic play technique: Its history and significance. In Klein, Melanie, Heimann, Paula, and Money-Kyrle, Roger E. (Eds.), New directions in psycho-analysis, Tavistock Publications, London
2. Miller, A. (1998) ‘Two psychoanalytic approaches’ in Thou Shalt Not Be Aware, Pluto Press, London 
3. Mordock, J. B. (2001) ‘Interviewing abused and traumatized children’ in Clinical Child Psychology and Psychiatry 2 (2), Sage, London
4. Winnicott, D. (1967) ‘Mirror-role of mother and family in child development’ in Playing and Reality, Winnicott, D. (1971), Penguin, London
5. Mordock, J. B. (2001) ‘Interviewing abused and traumatized children’ in Clinical Child Psychology and Psychiatry 2 (2), Sage, London
6. Raskin, D. C. and Esplin, P. W. (1991b) ‘Statement validity assessment: Interview procedures and content analysis of children’s statements of sexual abuse’ in Behavioural Assessment 13, 265 – 291, American Psychological Society, Washington