Jeanine Connor has written a regular column for 'BACP Children & Young People', the quarterly journal for CYP professionals, since 2011. 

 'Reflecting on...' allows free rein (and a tiny word count) to write about anything pertinent to psychotherapeutic work with children and young people. 

The columns contain an amalgamation of therapeutic experiences, events and individuals are unrecognisable.

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Reflecting on... Sugar babies

coming soon

 

Reflecting on... Attention Seeking

A number of my clients are described as attention seeking by (mostly) well-meaning observers. Behaviours include being silly, clingy or feigning illness, as well as various acts of self-harm, including suicidal actions. Attention seeking is perceived as a derogatory term – which belittles the behaviour and suggests that both it and the individual shouldn’t be taken too seriously. Yet the arrival of the attention-seeking client in my clinic suggests that, after all, they are being taken – ever so slightly – seriously.
I often ponder aloud why the young person feels they need to do something that silly or that risky for attention. I’m encouraging a dialogue about what their actions might mean, because they need to be acknowledged and understood in a way that feels good enough. There isn’t a ready-made formula, so we need to work it out together. I try to model communication that acknowledges the action without judging the individual, and I express my curiosity from a position of ‘not-knowing’. The not-knowing bit is powerful because young people are often in that position themselves. It can be reassuring to have someone join them there rather than preach from a position of superiority.
And I don’t know why this person has taken an overdose, or that person makes rude comments, or the other one cuts, but I do know this: they want someone to notice and they want, at some level, someone to know how it feels. There might be clues in the act itself, but also in the context. 


I might wonder aloud about the sense of loss that may have preceded the overdose, and go on to explore the young person’s beliefs about life and death. I might notice that the challenging behaviour began around the time that Dad left, and that it might feel as if he isn’t bothered anymore because his visits are so inconsistent. And I might wonder at the challenges and uncertainties of adolescence with the young person who self-soothes by cutting.
Just as the distressed baby will cry louder until its needs are met, the troubled child or adolescent will escalate their efforts to be noticed. And just as the non-verbal baby relies on an attentive (m)other to understand their needs, so, too, the child or adolescent who nds it hard to verbalise their distress might require help in working it out. It’s time to stop dismissing attention-seeking behaviour and start recognising it as a vital communication from a young person who wants to be heard.

(Published in BACP Children & Young People, September 2017)

Reflecting on... 


Afterwards

I recall the moment a former client popped up on my television. I recognised the voice, before the face, as one I’d attended to for over 100 hours. Once the realisation about who it was struck me, I switched the television off. Obviously the now 18 year old had consented to public viewing, but it felt awkward to have them in my personal rather than therapeutic space, albeit via the TV. Naturally I was curious about what happened to them afterwards, but in that split second decision to switch off, I ensured that our therapeutic ending remained intact.

That experience prepared me for the now relatively common phenomena, in my work with young people especially, of the friend request. I explain to existing clients that our relationship remains within the therapeutic space to protect our individual privacy as well as that of our friends and families. I know counsellors who search their client’s social media profiles out of curiosity. For me, technological snooping crosses a boundary and feels intrusive. If I want to know more about a client I ask, I don’t spy. If they are inquisitive about me I encourage them to do the same. Even though I don’t share personal details, I think this models honesty and respect and it holds the therapeutic boundary.   

Requests from former clients, and sometimes parents, are trickier to refuse. I will have wondered how they have developed and whether our therapeutic work has been kept in mind. So when their name pops up informing me that they have remembered I’m delighted to hear from them and tantalisingly close to satisfying my own curiosity. 

So when their name pops up informing me that they have remembered I’m delighted to hear from them and tantalisingly close to satisfying my own curiosity. But I decline their invitations and respond instead by private message saying I’m pleased to hear from them and hope they are doing well. Some respond, some don’t, which provides clues about their motivations; increasing their ‘friend’ count, or a genuine desire to make contact. I know counsellors who accept ex-clients as friends, reasoning that once the professional contract is terminated, it’s a legitimate way of keeping in touch. I disagree. Clients have fantasies about me and my ‘real’ life as do I about them. I believe those fantasies should be maintained rather than contaminated by access to each other’s social media profiles.    

How we respond to clients afterwards should be as ethically informed as how we respond to them during. So before you accept a friend request from a client, former client, or parent, consider whose interests you are serving. If it’s your own; decline.

(Published in BACP Children & Young People, June 2017)


Reflecting on... 

Ordinary emotions

I had a referral from a mother struggling to manage her child’s oppositional behaviour. She wondered if he had ADHD and wanted to know if I could offer anger management; to him not her, although she sounded very angry on the phone. Archie was three and was a delight, curiously poking his nose and fingers into my things and asking endless questions during our consultation. I congratulated his mother on her bright and inquisitive child and modelled firm containment; ‘There are things in this room that are private and I’d like you not to touch them. Why don’t you have a look over here instead…’ Archie responded age-appropriately, by testing the boundary but staying within it once he realised it was firm. His mother expressed relief that there was nothing ‘wrong’ with her son and admitted her anxiety about being a good-enough mum.

I had a request for bereavement counselling for nine-year-old Oliver who was clingy, not wanting to leave his mother’s side. When I learned that his grandmother died just a week ago, I wondered aloud if Oliver was afraid that something might happen to his mum; that she might die too, and that’s why he wanted to keep her close. He nodded that he was. I pondered aloud that mum was probably distracted by her own grief and preoccupied with funeral arrangements so that Oliver might feel lonely. They didn’t need bereavement counselling; they needed to be reassured that it was ok to be sad together.    

A referral from school for seventeen-year-old Essie outlined concerns about depression, self-harm and suicidal thoughts. Essie told me she was struggling with UCAS and coursework. She hadn’t self-harmed and didn’t want to die. On the contrary, she had a clear life plan and wanted to be a success! She wasn’t depressed but she was understandably anxious and had told her teacher she ‘wanted it all to end’. ‘It’, I discovered, encompassed exams and choices which had become overwhelming. After verbalising her thoughts with me, Essie said she felt lighter. I’d listened and normalised her feelings and fears. 

I met each of these young people for a consultation but I offered none of them individual therapy. They weren’t mentally ill and they didn’t need psychological support. These referrals are examples of a worrying trend to pathologise ordinary emotion. Toddlers have tantrums, children feel insecure, adolescents fuss and fret And that’s ok. We should encourage them to feel and display emotion. It’s a healthy thing to do J


(Published in BACP Children & Young People, March 2017)

Reflecting on... Ann 

(unpublished) 

The Ken Loach film I, Daniel Blake portrays the stark reality of poverty and need for its two central characters. Daniel can’t meet the requirements for Job Seekers Allowance because his cardiac consultant deems him unfit for work. But he is ineligible for disability support because a health assessor judges him too well to claim. Single mother Katie is rehoused in an unfamiliar part of the country. As a consequence, she takes the wrong bus, misses her signing-on slot and receives a financial sanction. She can’t afford to heat her damp, dark flat and is reliant on food-banks to feed herself and her two young children.

Daniel and Katie have stayed with me, but I’ve also been reflecting on Ann.

Ann works at the benefit office amongst a staff team depicted as hard-hearted jobsworths. They do what they are paid to do without deviation or emotional involvement, but Ann is different. She demonstrates empathy and understanding, offers support and kindness and is disciplined for it by a faceless manager who warns her to play by the rules and not get involved. I recognise Ann and identify with her predicament.       

The benefit office segments feel familiar. They depict what happens in any number of organisations where ‘service users’ find themselves caught between a rock and a hard place, this benefit or that, one service or another. Clients slip through nets, their mental-health deteriorates, sometimes they die. 


The way to hang onto those precious jobs is to tick the box, not get involved and not ask questions, especially about the inadequacies of the system.


Resources are diminishing in correlation with rising demands and tightened referral criteria. Professionals debate the origin of the problem – It’s environmental! No it’s health! No it’s education! – in order to gate-keep and protect their own workload. There is no time or inclination to think or work together. Stretched community counsellors hammer at the door of tier three services where stricter gatekeepers reside. Clients are admitted if there is a crisis, if not, the wait will be long. Once inside, there is pressure to get them out, until they are re-referred. Most services seem to operate a revolving door.

Serious incidents are increasing. Staff burnout and turnover is high. The way to protect yourself is to be an automaton, turn up, tick the box, discharge the client. Repeat. Thankfully, there are some of us who are still willing to get emotionally involved, to accept complex clients onto our case loads and bend the rules to protect their well-being, often risking our own in the process. We are the Anns of the services. Our clients deserve us to be more Ann.  


December 2016 - unpublished 

(Admitting) The T word

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, 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.

Conclusion

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). 

References  

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, http://news.bbc.co.uk/1/hi/health/4530743.stm 10. Therapy Today, July 2016, Keeping up with our clients 

(First published in BACP Children & Young People, December 2016)


Reflecting on... Ink

A quick straw poll suggests those above an arbitrary figure denoting middle age are against their public display, while those in the younger bracket are indifferent. Historically, tattoos were a male-dominated pursuit associated with soldiers, sailors, hoodlums and chavs. Today it seems no self-sanctioning celebrity is without one, so too 40% of 18 – 29 year olds and 21% of all UK adults irrespective of gender, class or aspiration. *Hushed whisper* - counsellors have them too. The figure for under-18s is unknown, largely because the Tattooing Of Minors Act (1969) deems it an offence. However, 

a good proportion of my adolescent clients have tattoos and, legalities aside, I’m interested in the whats, whys and whereabouts of their ink.


While purely decorative swishes and swirls may be de rigueur in certain circles, adolescents appear inclined towards something more blatant. I’ve observed graphic representations of parents who have died or siblings who have been separated. Tattoos that symbolize loss are particularly popular (and pertinent) amongst Looked After Children. They communicate that they weren’t always alone; once upon a time they were part of a family and their disconnected family remains part of them still.


It’s become common for young couples to have each other’s names indelibly etched to signify their commitment. The relationship may be faltering before the ink is dry but they don’t want to hear that, or the warning that they’re likely to regret it. They wouldn’t be in the relationship with the matching tattoos were they not certain it would last; they’re not stupid. On the contrary, these tattoos demonstrate love and devotion to someone who loves and is devoted to them in return, perhaps for the first time in their life.


They wouldn’t be in the relationship with the matching tattoos were they not certain it would last; they’re not stupid. On the contrary, these tattoos demonstrate love and devotion to someone who loves and is devoted to them in return, perhaps for the first time in their life.


Alongside the increase in tattooing has been a rise in demand for removal. I’ve seen some dreadful tattoos, the perpetrators of which were never identified for legal reasons. Misspelt names, unrecognizable images and meaningless symbols abound. Relationships fail. Tastes change. Skin sags. The young grow up. If only a leaf had been taken from Totally Tattoo Barbie’s book (yes it’s a thing) and a temporary version of their love-interest’s name had been opted for instead.

Adolescents are conspicuous consumers of fast everything. Relationships develop from swipe-right to fourth-base in days. Phones, tablets and other gadgetry are ‘old’ within months. In a life where nothing lasts for long, it’s curious that so many young people are opting for something with the potential to last forever. 


(First published in BACP Children & Young People, December 2016)

Reflecting on... 

Transgender

Some boys develop into big, strong men. Others become beautiful women. Most are somewhere in between. Gender, like sexuality, is not a binary concept. Working with transgender clients I often ask questions such as ‘how do you identify?’ or ‘will you tell me if I get it wrong?’ This directness rarely causes offence. On the contrary, an honest acknowledgment of comfortable not-knowing provides relief from the more familiar experiences of assumption and prejudice.

 Julia was born female and came to therapy to explore her feelings of wanting to be male. She was already known to specialist transgender services and planned to undergo surgical transition. Julia dressed like a boy, had a boyish haircut and bound her breasts to disguise her feminine curves. She looked masculine but her pre-op identity was trans-female. I referred to her as ‘she’ because that’s how she identified.

 Lauren was born male but perceived herself as female. She told me she didn’t want to be a girl; she was a girl. I called Lauren by her preferred name and referred to her using the preferred pronouns. I remained respectful but not disingenuous. When Lauren told me she was a girl just like me, I challenged her by pointing out that our bodies were different; mine has a vagina and breasts, hers a penis. We explored this unbearable truth together


 Teresa was a pretty girl with coquettish mannerisms. She wanted me to call her Troy because she felt like a boy. I worked with Teresa/Troy for a number of years and her identifications zigzagged. We discussed her homosexual feelings towards girls. When she got a boyfriend we explored her straightness. She wondered, if she felt like a boy, whether her attraction to boys was homosexual. Together we travelled the ambiguities of adolescent sexuality.Philippa was born male and presented as a strikingly beautiful young woman. She was confident in her sexuality and comfortable about her transgender status. Therapy involved finding ways for Philippa to manage her ritualistic behaviour as she embarked on leaving home and starting university.

 It’s always a pleasure to be permitted insight into young people’s worlds to help them make sense of them. Not from a position of authority, but from alongside, negotiating the journey together. Working with transgender clients affords an additional privilege because they’ve often been supremely private. We must not shun this gift but accept it gratefully and work with it candidly.

(First published in BACP Children & Young People, September 2016)

Reflecting on... Justin Bieber

There’s a certain 22-year-old who’s become a frequent presence in my therapy room. Prepubescent girls bring his face on lunchboxes and book bags. Adolescents bring his music via smartphones and tablets. Parents discuss their children’s obsession, and confess that they quite like him too. Type ‘Justin Bieber’ into Google, as I did, and you get 153-million results. Bieber-fever has reached pandemic proportions and I’m wondering why.

 Justin Bieber is the only child of unmarried parents who separated during his early years. His proud single-mother uploaded videos of her son’s amateur performances to YouTube. A marketing executive stumbled across them, liked what he saw and signed 13-year old Bieber to a record label. It sounds like a fairy tale, although the family might call it divine intervention. They are practicing Christians, and Justin doesn’t hide his strong moral, and sometimes controversial, beliefs about suicide, abortion and rape.

The rags-to-riches story has universal appeal. Hopeless, stuck, struggling young people tell themselves – if him, maybe me too. Many identify with the humble beginnings, absent father and poverty, but also with Bieber’s lyrics, which I’ve spent many therapeutic hours scrutinising.

 

 The break-up of a controlling relationship is explored through ‘… you told me that you hated my friends the only problem was with you and not them… you told me my opinion was wrong…’ And many adolescents identify with the effusive apology: ‘…you know I made those mistakes maybe once or twice. By once or twice I mean maybe a couple of hundred times’. While experiences in a multitude of relationships are epitomized in ‘First you're up, then you're down and then between. I really want to know... What do you mean?’ Scratch the surface and these lyrics help put words to feelings and experiences that young people would otherwise struggle to express. 

But Bieber is not just a squeaky clean popstar who writes loquacious lyrics. He has drive, ambition and talent. He has faith in God, yes, but also in himself. I try to arouse this latter quality in my clients. With the spotlight so often on their failings, I wonder about their dreams and passions. I encourage a shift in focus from what is lacking to what they have to gain. I demonstrate my belief that they have a choice to create a better future, despite their past. If having Bieber in the therapy room helps with the process, bring him in! 

(First published in BACP Children & Young People, March 2016)

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Reflecting on... fairy stories

My clients have been telling me fairy stories. Six-year-old Jonas told me about the wild beasts that come into his bedroom at night. They have sharp fangs that bite him and big paws that grab at his tiny body. He attempts to scream but can’t make a sound. He struggles to move but feels pressed down. The beasts have faces he recognises. Jonas’ mother has presented him to adult men and women for sexual gratification; beasts in human form that violently molested him.

Milo is ten and relishes telling me about his adventures. He says his mother is in a coma and could die. When Milo arrives at sessions looking exhausted he tells me that he and his stepfather have been clubbing, drinking beer and talking to pretty ladies. They fight with rival gangs, and always win. Milo’s mother is not unwell, but in his narrative Milo is communicating his sense of her as absent and ineffectual. His stepfather is prone to violent rages. In Milo’s fantasy he is grown-up and they are on the same side.

Twelve-year-old Sammy-Jo is certain she’s a mermaid and is trying to convince me of this too. She tells me that her mermaid tail appears when she gets wet below the waist because her mother gave her a potion of crushed pearls and seawater when she was a baby. 

Sammy-Jo has severe learning difficulties and was sexually abused by her mother as an infant. She is struggling to manage menstruation and is often ‘wet below the waist’ due to poor hygiene.  Mermaids have ambiguous genitalia and they are unable to stand on their own two feet. Sammy-Jo’s identification symbolises her incomprehensible sense of her adolescent self. 

Children who have been sexually or physically abused in particular have confused internal worlds. They cannot comprehend what was done to them and other people find it unbelievable too. So they invent stories, either as a means of escape, like Milo, or in an effort to make sense of their experiences, like Jonas and Sammy-Jo. But all their stories are autobiographical and so I tread gently, staying with the symbolism and responding to the feelings – ‘Those beasts sound terrifying…’ ‘It seems like you enjoy feeling strong with your stepdad …’ ‘I wonder what it feels like to be a mermaid…’-. I don’t challenge the children to ‘stop telling me fairy stories and tell me the truth’ because I recognise that they already are. 


(First published in BACP Children & Young People, March 2016)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==

Reflecting on... foreign bodies

The therapy room is no place for politics; except everything seeps in here! One boy, Peter, told me about his recent trip to France and the migrants he witnessed at the port. The nine-year-old told me he was worried they would touch him and he hopes they are prevented from coming here because they carry diseases. I wondered about the messages he’s picked up from the media and from politicians visiting our corner of the South East. Peter perceives migrants as ‘foreign bodies’, literally antigens that could infect our green and pleasant land. I had a role in helping Peter to make sense of his experience, one that had felt threatening and nonsensical because of its unfamiliarity, and in helping him to explore difference.

 Eight-year-old Alison Piper lives in a caravan with her large traveller family. People at school call her Pikey Pauper because they think that her family can’t afford to live in a house. Alison is one of the neatest, well-presented little girls I’ve met and she doesn’t understand why her peers think she’s dirty. I try to help her to make sense of the nonsense. 

The children have noticed that Alison is different to them and that makes her a ‘foreign body’ in the school. Lots of people are frightened of the unfamiliar. Sometimes when we’re frightened we get angry and cruel to make the other person feel more frightened than we do.

 Alison begins to warm to the children at school. She’s not afraid of them anymore, but is keen to demonstrate that, as well as difference, there is sameness too.

Difference is confusing. Social etiquette makes us feel we must accept rather than question so that we are silenced by political correctness. I welcome curiosity and I model it too. I tell my transgender client I don’t understand. I encourage my Jehovah’s Witness client to tell me about his beliefs. I ask the nine-year-old what he fears about people from other countries. 

Difference should be questioned; it’s how we learn, and so should our beliefs. Where did they originate?  Are they true beliefs or ones we’ve simply conformed to? Does experience support or refute them? Do we believe them still? An unquestioned belief can be like a foreign body, festering away and causing harm. Reflecting honestly on our beliefs, and modelling curiosity to our clients about difference, develops our understanding. Difference feels less alien, less frightening and a whole less ‘foreign’.

(First published in BACP Children & Young People, December 2015)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==Reflecting on... labelling

I’ve been watching another one of those television series about children who are out of their parent’s control. You know, the ones that aim to determine whether the child is mad or bad. The experts decided it’s 50/50 – well they would wouldn’t they; this is mainstream telly and they have to perch politely on the fence. Diagnoses doled out included the usual gamut of ADHD, ADD and ASD as well as the more controversial Oppositional Defiance Disorder (ODD) and Pathological Demand Avoidance (PDA). Parents have been relieved when their child receives a diagnosis because it lets them, the parents, off the hook. This is the cynic’s opinion. 


The positive aspect of receiving a diagnosis is that it opens a door to treatment and support. We see countless families, both on television and in practice, that have struggled on for years finally getting better. It’s not the label that makes the difference but access to the right educational and/or therapeutic provision, denied to those who deserve it because of a lack of understanding about their needs. 

A diagnostic label is a shortcut to explaining behaviour and a ticket in to services. But it acts like a stereotype in that it only partially explains the idiosyncratic reality of each child. Let’s consider ASD.  

The authors of DSM-V have made Asperger’s Syndrome obsolete and instead included it in the spectrum of autistic disorders. I would argue that all normal and disordered behaviour lies somewhere along a continuum, which individuals oscillate up and down depending on situation, context and mood. On any given day, any one of us could be labelled with some disorder or other; depression, anxiety, ADD, PDA, but it doesn’t mean that we should. What would be the point of that?


It seems that the point for many families is that without a label there is no support. For some it means that things have to reach crisis point before their child meets the necessary criteria of the necessary agency that is equipped to make a diagnosis. Others feel the need to exaggerate their difficulties so that they do. The third option, it seems, is to apply to a television programme, which provides a fast track route. While the fourth, rarely mentioned, option is to pay for a private diagnosis. Everything has its price.


I saw an advertisement for a drinks company recently that read ‘Labels are for bottles’. They are also for children, and without one many are screwed*. (published article reads 'overlooked' in place of  'screwed).     

(First published in BACP Children & Young People, September 2015)

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==

Reflecting on... unconscious communication 

I have an attractive female client, let’s call her Polly. She’s eighteen, slim, immaculately made-up and fashionably dressed. Every week she compliments me on my appearance; ‘You look nice today’. ‘I like your hair’. ‘Are those new shoes?’ She’s socially polite and we’ve talked about her desire to be compliant and likable. She’s exceptionally observant and we’ve explored the ways her vigilance links to her experience of trauma. But Polly has noticed something about me too, the reflexive grimace that crosses my face when she comments on my appearance. It’s almost imperceptible, but not to Polly who says huffily that I can’t take a compliment.


I’ve wondered about this weekly exchange with Polly. Perhaps her compliments communicate something about our relationship that by focusing on her story I’ve been missing. She notices that I bother to tidy up my hair and think about my clothes before I meet with her which demonstrates that I think she’s worth the effort. Her comments could therefore be interpreted as gratitude; ‘thanks for caring’. I know from her narrative that not everyone pays her this level of respect. 


She’s talked explicitly about the time she met her mum for coffee, who was scruffily clad in tracksuit and trainers but had a dress and sandals in her bag to change into before she went on to lunch with a friend. 

She’s mentioned a teacher who showed her the jacket she’d purchased at lunchtime but quipped that it was much too nice to wear to school. I’ve heard about the berated boyfriend who refuses to dress up for date nights but has no qualms about doing so for drinks with the boys.  is important to Polly; it’s one of the few things she can control. Her compliments are communicating something of the importance of my appearance too and what it symbolises for her about our relationship. The clues have been there all along in what Polly shares about her other important relationships but I’ve only just noticed them.

So when Polly commends how I look it isn’t really about me, it’s about us. Her unconscious communication is ‘I’ve noticed you care about me and I’m grateful’. On reflection, my responsive grimace, however subtle, is rejecting her gratitude and negating her hope that I care. ‘You can’t take a compliment’ feels accusatory and attacking precisely because Polly feels attacked. I must learn to accept the compliments with good grace and be ever mindful of the subtleties of my unconscious communications. 

(First published in BACP Children & Young People, June 2015)

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==

Reflecting on... mundanity 

When I submitted my previous column, Reflecting on... Operation Yewtree, there was a suggestion that it lacked some of my usual pizzazz. I conceded the point, but felt that what I’d said needed saying and said it anyway. On reading the December journal I was struck by a recurrent theme of what can’t be talked about. For example in Cath Knibbs excellent ‘Cybertrauma’ as well as Nick Luxmoore’s brilliant pieces ‘How do I look’ and ‘Talking About Sex’. 


I recently attended a counselling workshop with the same title as Nick’s column (no connection) and was struck by how uncomfortable counsellors were with acknowledging the sexual life of their adolescent clients. I was shocked to discover that many of them weren’t talking about sex at all as it’s a pretty regular topic in my own therapy room. Ditto my client’s activities in cyberspace. 


Several participants recognised my name as the one they’d read in this journal. They remembered me talking about shitty families, constipated systems, violent computer games and BDSM. It was reassuring to hear that people are actually reading this stuff and that their thinking has been stimulated by what isn’t usually said; either in print or in the therapy room.


And that’s the key thing here; my clients, colleagues and readers recognise me as someone with whom that which can’t be talked about can. Anything goes. 

But just as there’s a time for pizzazz, there’s also a time for mundanity. Not every clinical encounter will contain a ‘eureka’ moment. Not every session will feel stimulating, for us or our clients. Some sessions will be dry, dull and monotonous. Time will be spent checking-out the meaning of what our clients bring and making sure we’re speaking the same language. We’ll refer back to previous sessions and issues around boundaries, confidentiality and safeguarding time and time again. We’ll discuss things our clients have heard about in the media and how it might relate to them. 

It’s been impossible to ignore Operation Yewtree, which has made several appearances in this journal as well as therapy and supervision sessions since its conception. There’ll be times when we don’t know what’s going on, times when nothing seems to be going on and that’s ok; it’s all part of the therapeutic process. Mundanity is reassuring and safe. It provides the secure base from which our clients can talk to us about anything at all; with or without pizzazz. 

 
(First published in BACP Children & Young People, March 2015)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==Reflecting on... Operation Yewtree

Jimmy Savile. Rolf Harris. Gary Glitter. Household names of an 80s childhood. Men who found notoriety on the role-call of Operation Yewtree. Publicity surrounding police investigations has led to terms such as grooming, paedophilia and child pornography entering popular vernacular, often inaccurately. It has also led to widespread mistrust and mislabelling and it’s time to set the record straight. 

 

‘Paedophilic disorder’ is a paraphilia characterised by sexual fantasies and urges towards prepubescent children (DSM-5¹). Diagnostic criteria states that symptoms are present for at least six months and include: the presence of sexually arousing urges, fantasies or behaviour towards prepubescent children in individuals aged 16+, and that the fantasised children are at least five years younger than the perpetrator.  Not all individuals who molest children are psychiatrically unwell paedophiles. Nor are older adolescents who engage in sexual activity with younger adolescents. Psychiatric classification systems exempt them and rightly so.  

 

Grooming is a criminal offense whereby an adult with sexual intentions towards a child elicits a meeting. The objective is sexual contact, trafficking, prostitution or the production of explicit images. So called ‘stranger danger’ has been drummed so vehemently into so many children that every adult is viewed with suspicion. This is a terrible shame. The act of befriending a child does not equate to grooming and the majority of adults have benign intentions towards them.

 Child pornography is a misnomer. Images labelled as such are representations of child sexual abuse. Furthermore, research suggests that an extensive collection of such images is a strong indicator of sexual fantasy and intent. The creation, storage and circulation of sexually explicit images of children is a crime. The growing trend of sharing sexually explicit ‘selfies’ with same aged peers is imprudent and ill-advised but it isn’t criminal and nor is it paedophilic.    

 

Operation Yewtree has highlighted historical and truly heinous sexual crimes and this has led to the conviction of guilty men. But there have also been a number of high and low profile investigations that have not resulted in convictions. Some say there is no smoke without fire. What I say is, let’s educate ourselves and others so that we are at least speaking the same language. Let’s equip young people with the capacity for safe decision making with regards their sexual behaviour. Let’s continue to implement professional curiosity. But please let’s not forget to exercise our common sense. 


1.         DSM-5: Diagnostic and statistical Manual of Mental Disorders, Fifth Edition (2013) American Psychiatric Association  


(First published in BACP Children & Young People, December 2014)

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Reflecting on... throughput

In the June issue I reflected on ‘shittiness’ and how it gets projected by families into those of us who work as therapists. I inferred that professional systems are feeling shitty too and would like to elaborate. A current buzzword in therapeutic services is ‘throughput’. The idea is to uphold a model where clients are referred, assessed, treated and discharged in a short, smooth, seamless process, never to be seen again. The bit in italics is what I believe to be the implied fantasy. I’ll tell you what else I think... 

 

Throughput has connotations of passivity which is in direct conflict with the ubiquitous, and in my book equally objectionable, concept of ‘empowering’. How can we hope to facilitate recovery if clients are put through a series of predetermined, time-limited, robotic motions? We can’t. Or maybe we can, but the upturn will only be short lived so that a ‘revolving-door’ service is created where clients come in for their short fix then get discharged, then get referred again, then get discharged, ad infinitum. 

 

Throughput is based on fantasy. The reality is that demand for most counselling and therapy services outweighs supply. In some postcodes waiting lists for tier 2 (community) and tier 3 (specialist) services are many months long. But in services where they are playing the throughput game it’s different. Clients get an assessment within weeks of referral; sounds good, but then they wait months to meet a specialist counsellor, therapist or psychiatrist who can provide them with the service they need.  Throughput is good for the headlines: ‘Waiting lists down to two weeks’ but not so great for the clients who need help now.

Clients get an assessment within weeks of referral; sounds good, but then they wait months to meet a specialist counsellor, therapist or psychiatrist who can provide them with the service they need.  Throughput is good for the headlines: ‘Waiting lists down to two weeks’ but not so great for the clients who need help now. services are constipated. There’s more going in, in terms of new referrals and existing ‘service users’ (another horrible term) than is coming out, in terms of discharge. Why? Because clients referred for counselling and psychotherapy are complex individuals with multifarious needs; that’s the nature of the beast. 

Professionals are being asked to flush the system through and get clients out the other end without touching the sides. But some of us are struggling with this. I entered the profession to make a difference and that involves taking time to build a relationship with the client and their family (all the evidence supports this), to listen to their story and work at their pace. I didn’t sign up to be a human laxative. 


(First published in BACP Children & Young People, September 2014

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==

Reflecting on... shittiness   

I love my work, but things have felt quite shitty lately. I think this says as much about the systems I work in and the families I work with as it does about my own state of mind. It’s as if their ‘shitiness’ has got into me and it’s making me feel somewhat constipated, psychologically speaking. I’m not being flippant; I’m using ‘shit’ as a metaphor. Here are two examples. 

 

As a 10-year-old arrived for therapy I noticed soiling on her skirt. She didn’t mention it and neither did I. Instead I observed as she made messy pictures letting paint spill off the page, seemingly unaffected by the consequential mess. The following week she arrived; same skirt, same shitty stain. This time I decided to speak to her father to find out what was going on. He hadn’t noticed. Dad was increasingly depressed since his wife left 3 months ago, unable to cope with her own mental health issues and those of her daughter. I wondered about those parents sending their ‘shitiness’ to me on/in their daughter because they couldn’t bear to think about it.


An 8-year-old was referred for constipation. There was no apparent physical cause and the GP had suggested therapy as a ‘last resort’ (isn’t it always?). The boy had a diagnosis of ASD and mum described him as rigid and controlling, unable to learn or make friends, with ‘a sadness deep inside’. 

 An 8-year-old was referred for constipation. There was no apparent physical cause and the GP had suggested therapy as a ‘last resort’ (isn’t it always?). The boy had a diagnosis of ASD and mum described him as rigid and controlling, unable to learn or make friends, with ‘a sadness deep inside’. I heard the family’s story of multiple losses and how mum kept her own sadness hidden in order to protect her children. I wondered about the emotional constipation affecting each family member who felt unable or unwilling to express their emotions for fear of making things more ‘shitty’.

Other people’s ‘shit’ is the stuff of therapy, metaphorically speaking, and our job is to acknowledge and explore it in a way that makes it feel less shitty for the families in our care. Whether it’s spilling out and messy or compacted and retained, its quality tells us something of the problem. Continuing the physiological symbolism; we need to consider what’s being ingested [too much, too little or not nutritious enough?] and how it’s being metabolised [too hurriedly or not mindfully enough?]. Reflecting on the shitiness, as I did with the two families exemplified here, helped to rebalance their emotional diet so that it was more easily digestible and, well, less shitty.  


(First published in BACP Children & Young People, June 2014)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==

Reflecting on... doing nothing

A colleague was struggling with an adolescent client he’d been seeing for several months. The client attended every session and mostly sat in silence while he, the therapist, sat silently too. He was considering ending the therapy, which had already been reduced to fortnightly, due to his client’s difficulty in engaging. Every session left my colleague feeling drained and often with a headache. He felt frustrated and didn’t know what to do. When I wondered what he thought he was doing he replied ‘I’m doing nothing!’ We explored ‘doing nothing’ in the context of the client’s story.  

The client was a child in care who had moved placements and been excluded from school since starting therapy, repeating an all-too-familiar pattern. Her social worker had resigned and not yet been replaced. She had sporadic contact with her parents who were separated and each had new partners and new children; her own half siblings who seemingly took priority over her in their parent’s lives and minds. Father’s partner was pregnant again. I felt an immense sadness in relation to the multiple experiences of rejection and abandonment this girl had experienced. I thought her sense of being un-wantable must be overwhelming and her projections so powerful that her therapist was considering abandoning her too. We considered how the therapeutic relationship seemed to mirror others, where contact had been reduced or terminated and now the therapist wanted to get rid of his unsatisfying client in order to make space for a new, potentially more rewarding ‘baby’.    

 We considered how the therapeutic relationship seemed to mirror others, where contact had been reduced or terminated and now the therapist wanted to get rid of his unsatisfying client in order to make space for a new, potentially more rewarding ‘baby’.     

But, rather than ‘doing nothing’, he had contained his client’s projections week after week. He’d felt useless, hopeless and deskilled, just as she did, but he’d endured those feelings alongside her. At other times he’d sensed the parental transference and felt punishing, hating and rejecting. So far, much of the communication between therapist and client had been unconscious and nonverbal, but there had definitely been communication. Why else would she keep coming back? My feeling was that she sensed something nurturing in the therapeutic relationship; it wasn’t harsh or judgemental, but it was real. There were no rights or wrongs, she could just ‘be’ and perhaps, most powerfully of all, experience another person just being with her too. 

How valuable that space must have become for a girl who lacked any consistent, dependable, safe space, and what a wonderful thing to provide for her. Doing nothing? Not at all!  

(First published in BACP Children & Young People, March 2014)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==     Reflecting on... Being old enough 

Six-year-old Jessica talked about her hamster. ‘He looks funny and doesn’t want to play anymore.’ Jessica’s hamster had died but ‘because she’s too young to understand’ her parents substituted the much-loved pet with a replacement hamster and said nothing. Two adolescent brothers have diagnoses of schizophrenia. Their ten-year-old brother Miles has a worrying presentation which requires assessment. An offer of family therapy has been accepted but the boy’s parents don’t want Miles to attend ‘because he’s too young to understand about mental illness’. Eight-year-old Leon’s grandfather died. They’d had a close relationship before Leon went into care and became estranged from his family. Professionals decided that Leon was ‘too young to attend the funeral’.  Twelve-year-old Elsie believed she was becoming a monster. Evidence for this was hair on her ‘privates’ and blood in her knickers. Elsie’s father withheld consent for her to attend sex education classes throughout junior school ‘because she’s too young to know about that sort of thing’. 

 

Anecdotes like these make me incredulous at adults who deny children knowledge about their experienced realities. Not-knowing is an unbearable position so inevitably, ‘unknowns’ are filled with worry or fantasy; ‘my hamster is sick’; ‘my grandfather didn’t love me’; ‘I’m going mad like my brothers’; ‘I’m a monster; I’m bad’. Consequently, these negative beliefs manifest as ‘acting-out’ angry behaviours or ‘acting-in’ withdrawal and despair. Adults seek to medicalise children when all they are trying to do is make sense of their experiences. This is buck-passing and abusive.

Adults seek to medicalise children when all they are trying to do is make sense of their experiences. This is buck-passing and abusive.

Questions come to my mind about what is unknowable or unthinkable about and by whom. It isn’t usually the child, equipped with innate curiosity. I have engaged in many ‘facts of life’ conversations in children’s therapy sessions. Initially, I wondered if this was beyond my remit but I would argue not. Therapy is a safe space where children bring their worries, fears and fantasies to be thought about and made sense of. 

So I have explored ideas about death with a six-year-old, explained the characteristics of mental illness to a ten-year-old, described what might happen at a funeral to an eight-year-old, and discussed pubescent development with a twelve-year-old. And I have done so confidently and candidly. Children are never too young [whatever their age] to be treated with respect and protected from ignorance. They can manage information about life, sex, illness and death if an example of being able to manage is modelled for them. They are always old enough for that.   

(First published in BACP Children & Young People December 2013)

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q==


 Reflecting on... 
the language of the care system

Working with Looked After Children (LAC) has offered a valuable opportunity to explore the unconscious meanings contained within the language of the care system. An emerging acronym for children in care is ‘ChiC’. For me, this redefinition has uneasy undertones of cute, fluffy fledglings needing a home. Is this how we’re supposed to think of children in public care? Is it supposed to make them more care-able-about? More foster-able, perhaps? 

 

Children are described as ‘taken’ into care which has connotations of an impulsive, unannounced act. Regrettably, this matches the experience of many LAC/ChiC who are not prepared for what is about to happen to them. Colloquial language describes sick people as ‘taken’ into hospital. Are children in care sick in some way they don’t yet know about? Will they get better? Will they die? For many children, the emotional pain of not-knowing feels like a physical illness; while the loss and uncertainty is as dismal as death.


Many children imagine they must have done something dreadful if they are taken into care and language can perpetuate this belief. Children are ‘removed’ from home, while other things that are removed include tumours, cysts and warts; bad things that cause harm and which, once removed, leave us feeling relieved. 

‘My parents are better off without me’ is an all-too-common refrain, which can be interpreted as ‘now the bad me is gone, the good parent will be better/happier’. 

As is often the case, the children I work with describe their experiences more eloquently than I can; using language with a lack of self-consciousness that absolutely defines their experience. One child likened himself to a five-pound-note, explaining to me that, like money, he had been passed around between numerous owners and was usually kept in a dark place. As well as describing his experience of multiple carers, I think this metaphor also expresses his sense of self as an owned/passive object with little value. Like many children in care, he didn’t perceive himself as care-able-about and he couldn’t comprehend what was being done to him or why. 

 

Children encouraged to explore their experiences in their own language communicate in a profound way that gives us a real sense of what it feels like to be them. We must listen and we must ensure that their language is assimilated into the way we communicate about children who are looked after in the public care system.


(First published in BACP Children & Young People September 2013)

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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q== Reflecting on... what I do 


I am often asked what I do when I ‘do’ psychotherapy. Depending on who’s asking; a student, parent, potential client or service provider, my response varies. I don’t have any stock answers, in my experience, they don’t really wash. And anyway, non-psychotherapeutic people have watched ‘The Sopranos’ and ‘In Treatment’ and think they know what therapy is about. So what is therapy about?  

 

In theoretical terms, psychotherapy is about helping patients to think about, reflect upon and come to terms with what’s going on, or has gone on, in their lives. So far, so comprehensible. It gets complicated when I add that much of these ‘goings on’ are beyond conscious awareness. At this point the questioner does one of three things: 1. Glazes over, none-the-wiser, 2. Assumes I’m talking about Freud and all that [I quote] ‘wanting-to-shag-your-mother stuff’, or 3. Remains interested enough to want to know more; then repeats ‘but what do you actually do?’


If I’m feeling playful, which I often am, I might wonder what it is they think I do. Answering a question with a question is the stuff of therapy, right? This may sound glib, but there’s truth in it too, because wondering back, when a patient asks a question encourages joint exploration and demonstrates that I, the therapist, don’t have all the answers (and even if I did, I wouldn’t deliver them readily). 

 
 

 Patients frequently use metaphor to describe what therapists do. I hear about the ‘wounds’ that brought them into therapy, which has been described as ‘picking at’ or ‘uncovering’ something difficult. It sounds painful, and of course psychotherapy often is, as the defense mechanisms/plasters/scabs are gradually removed to reveal the unconscious trauma/wound beneath the surface. Only then can healing begin, and this can take a long time. As one patient who wasn’t ready to end treatment told me, ‘if I leave now, it will just scab over again but the badness will fester away inside me’. 

So when people ask me what I do when I do psychotherapy, they are usually asking what I can do for them/their child, and that depends on what they are ready, willing and able to do for themselves. If the time is right for them to start treatment, I will respect the defences that have served them well-enough for long-enough and be alongside them as they start to slowly remove the plaster and reveal the wounds beneath. We will examine those wounds together and try to make sense of them, and finally, with patience and compassion, we will embark on the healing process together. Because that is what I do. 

(First published in BACP Children & Young People June 2013)

 

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q== Reflecting on... suicidality

An increasing component of my work with adolescents involves assessing the risk of suicide. Our first meeting often comes at a time of crisis; when a young person has verbalised or acted upon suicidal ideation, perhaps by taking an overdose or cutting themselves very deeply with intent. This communication is often met with anger or confusion from parents and peers, which can lead to alienation. Sometimes an adolescent’s suicidality is over-dramatized, while at other times suicidal actions are dismissed as ‘attention-seeking’. In some respects that’s right; suicidal acts do attract attention, but the implied assumption that they need not be taken seriously is dangerous. 

 

My role, as well as assessing risk, is to take the suicidal adolescent seriously. Generally, they value the attention of someone who is interested in them and their story and this can lead to productive, long term therapy. Often it is their first experience of thinking with another about their vague and bewildering thoughts and feelings, which therapy can help make sense of.


 I like the definition of adolescence as a period of ‘sturm und drang’¹ (storm and stress). Instability and turmoil come with the territory, even for those with a stable, loving family to help them navigate the way. Charged by rampant hormones, the transition from childhood to adulthood brings forth contemplation about life, the universe and everything, but mostly, if we’re honest, musings about sex and death. This is both ordinary and terrifying. 

Freud identified an enduring conflict between Eros and Thanatos, the life and death instincts; the former, sexual and self-satisfying, the latter, antagonistic and hostile². Eros and Thanatos resemble adolescence personified when everything is perceived as a matter of life or death. Indeed, the trigger for suicidal ideation is often a relationship break-up, sexual confusion or poor self-image; experiences which challenge the adolescent’s sense of self, question their meaning of life, and intensify their sense of loss. With their childhood dying and their adult life gathering speed, Thanatos and Eros are in battle. 

 

So, when an adolescent presents with suicidal ideation they are contemplating their own life and mortality. Thinking alongside them about life and death can help to identify the internal alive and dead parts, leading to resolution of the life/death conflict. The adolescent who is taken seriously enough becomes less fragmented, their desire to be dead diminishes and they are freed-up to continue the journey into adulthood with alive, sexual potential. 

1.     Hall, G. Stanley. (1904) Adolescence: Its Psychology and Its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion, and Education, Vol I and II, New York, Appleton

2.    Freud, (1930) Civilization and its Discontents, London: Hogarth Press and Institute of Psycho-Analysis. New York: Cape and Smith

(First published in BACP Children & Young People March 2013)

 

Reflecting on... sex

In 2012, it became acceptable to talk about sex. ‘Mummy-porn’ transcended economic and educational status and everyone was talking about BDSM (bondage, domination, and sado-masochism). The new normality diminished people’s defenses and awkwardness. It facilitated communication and experimentation. It freed people up. The similarities to therapy are noteworthy. 

  

Inevitably, Fifty Shades of Grey¹ began to filter into adolescent’s therapy sessions. I found young readers’ responses uncomfortable. They weren’t fazed by depictions of BDSM because they’d been there, done that. Fair enough. While sexual experimentation is to be expected, whatever form it takes, of concern is the idealisation of the ‘Fifty Shades’ relationship and its effect on adolescent liaisons. 

 

Fifty Shades is essentially a romance between 22-year-old graduate Ana and 27-year-old businessman Christian. Adolescents can aspire to this without stretching the realms of possibility too far. It’s akin to the crush-on-a-teacher scenario; a naïve partner seduced by a sexually experienced authority figure. Christian is obscenely wealthy and turned on by controlling Ana, a physically and emotionally pliable virgin who is sexually up for anything. Their story depicts a common fantasy.


But many adolescents slip unwittingly into roles carved out by controlling partners, and into sexual relationships which are abusive. Social learning theory conditions them into believing that if they consent to whatever fantasy their partner suggests they will be rewarded with a grown-up, stimulating relationship. Christian is gorgeous, rich and powerful and uses his assets to stalk and control Ana who, despite her reservations, gives in easily. 

Christian is gorgeous, rich and powerful and uses his assets to stalk and control Ana who, despite her reservations, gives in easily.  clients give in easily too. I’ve heard from many who allow themselves to be controlled, sexually or otherwise. For them, the power imbalance and sense of danger is a turn-on. They have a dysfunctional and damaging model of relationships which tells them they must control or be controlled. 

When I discussed my anxieties with a colleague, they were horrified. Not by my clinical observations, but that girls as young as 13 were indulging in ‘clit-lit’ and BDSM. We can’t pretend this isn’t happening; ignorance is not bliss. Young people view porn and read erotica. This forms part of their sexual education. We have to be ready to explore and reflect with them about all kinds of sex and relationships. We must not abuse them further with judgement or ignorance but rather acknowledge their defences and manage their awkwardness (and our own) in order to free them up and facilitate communication, however uncomfortable this might be.


1.     E.L. James, Fifty Shade of Grey, 2011, Vintage Books

(First published in BACP Children & Young People December 2012)

 

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Reflecting on... hoarding

Compared to my usual case load of complex presentations, hoarding seems to be an uncomplicated condition, usually originating from loss and often characterised by disordered attachments. I am yet to receive an explicit referral of a child hoarder but signs of hoarding are implicit in my current case load, both physically and symbolically. 

 

Hoarding is described as ‘a pattern of behaviour characterized by the excessive acquisition of, and inability or unwillingness to, discard large quantities of objects that are seemingly useless or without value’1. This definition (and others) pathologises hoarding as a disorder which, by implication, demands treatment.  Assessment should be relatively straightforward: with little encouragement, hoarders can usually identify a trigger for their hoarding, which is inevitably the loss of a loved ‘object’ (in the Kleinian sense) or of something representative of ego; for example job, status or youth. Hoarders replace their losses with physical objects and form strong attachments to them to defend against their grief. Relationships with things then replace relationships with people.

 We are breeding a generation who want ‘stuff’ – lots of it – and who are becoming socially isolated, for (adult) fear of exploring the big bad world. Possessions pile up and relationships happen online. A young patient told me how she loves her messy bedroom, strewn with personal belongings. It makes her feel cosy and safe. In contrast, a room where everything is tidied away makes her feel lonely. She has no friends. She is in her ninth foster placement and is 10 years old. Perhaps she is demonstrating early signs of hoarding. 

From a psychodynamic perspective, hoarding is a fitting metaphor for the internal worlds of my clients. Many could be classified as ‘mental hoarders’, their minds littered with ‘large quantities of objects that are seemingly useless or without value’ but to which they remain firmly attached.  A deeply traumatised 15 year old client told me her mind feels like a ‘really messy room’. She isn’t ready to throw anything away yet, but she likes having my help to ‘tidy things up’. I feel privileged to be invited in and am treating her ‘hoard’ with care. 

(First published in BACP Children & Young People September 2012)

 

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LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q== Reflecting on... faith 

(in the process)


I remember being advised, as a trainee, to have faith in the process of therapy. I trusted my mentor wholeheartedly but this thing she called ‘the process’ was an enigma. Gradually, I began to disentangle the content of therapy from the thinking-about therapy, although initially, most of my processing happened outside of the consulting room. With clinical experience, the doing and the thinking-about became reconciled, so that for me, the process has a unique identity which is linked to, yet also distinct from, the content. This is a difficult concept to explain, and one I have struggled to illustrate to patients who are finding it difficult to ‘have faith’ just as I did.

 

Non-believers come in all shapes and sizes. Examples from my clinical practice include the child who wants me to set the agenda; the concrete-thinking father who draws me into philosophical debate and is reliant on logical argument in lieu of emotion; the abused adolescent who perceives each interpretation as an intrusive attack; the mother who screams ‘there is no such thing as the unconscious!’ right in my face; and the boy who yells ‘why do you have to analyse everything I say?’

 These clients are focussing on the concrete content of the session and finding it difficult to consider the process. Perhaps they don’t know how. Perhaps they would find it too unbearable. 

Non-believers can be colleague-shaped too; professionals from other disciplines who ask: ‘what do you actually do in therapy?’ A fundamental part of what I do is notice, name, digest, highlight and, perhaps most importantly, have faith in the process of the therapeutic relationship, as it alters and develops over time. 

As psychodynamic practitioners we understand the value of the therapeutic relationship in its own right as, what Winnicott called a ‘good-enough’ experience of maternal preoccupation. This is the process of therapy. In this we must continue to have faith.       


(First published in BACP Children & Young People June 2012)

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Reflecting on... hate  


The business of therapy and counselling involves empathy, nurturing, care and love. As therapists we are often on the receiving end of loving projections from our clients and this makes us feel good about our work and about ourselves. I think this is particularly apparent when our clients are children. So we reciprocate by loving them back, in the maternal, nurturing sense, so that we and they are enveloped in a circle of love. Love matters; it enables children to thrive and to survive out there in the big bad world. Therapy provides the perfect (aka ‘good-enough’) model of a loving, thoughtful relationship, incorporating maternal preoccupation and infant gratitude. How wonderful to make a career out of loving and being loved! 


But just as day needs night, love needs hate. So where is the hate in child therapy? We love children therefore we can’t hate them. If we did we would be hated back and that wouldn’t be very gratifying for anyone. I think hate can get split-off and lodged in our peer relationships at work; unconsciously and in a disguised form of course. 

  Hate gets played out in office banter, rivalry, dysfunctional meetings, ignored suggestions and cancellations. It is implicit in the invitation that goes out to all except one, and in the Christmas card that one colleague ‘forgot’ to send to another. 


These all-too-familiar experiences are subtle forms of attack and could provide clues about the [dis]location of hate. They are reminiscent of playground bullying which feels infantilising or empowering depending on our perspective. They re-enact the experiences of our clients so that our system replicates theirs and becomes just as chaotic and hateful. They cause us to feel unloved and taken-for-granted, resentful and suspicious. When we recognise that we are under attack we retaliate; we fight like with like, we hate back. Or, we retreat into absence from work. Or maybe we do something else. We might try to acknowledge the hate, name it, own it and take it to supervision where it can be given a fair hearing in a loving, thoughtful environment. Just the same as when our clients bring their own experiences of hate into the therapy room for us to know about on their behalf.


(First published in BACP Children & Young People March 2012)


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5LG2HyEdybd12Ym4bhYEg6p5TP1mjqa3RSa1kVpbdu3BKWm1KGM8iIM8RuajqSbbFiHM+z6Xe8KnSzoU33VQQBIUQZAG28A71Y1GgbHs5aIKy4VlCsoYgNC6QxHxRU8SV7ixtcyC0X1nVJbUwDbN49YDDmAwmiqStYGv/rtmCDqYHTILcl1wPbxtTxJCxi12csqpUa91dCdW8Npncc/CtV1ZCxDb7MIryGbRC+EnzMLpuS8cRqI224UdV2JY78kywYe3okElmZiBAJJ5DkAIA9AKzOTk7lLCsgUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAKAUAoBQCgFAf/2Q== 

Reflecting on... ending


Reflecting on endings during beginnings, and vice versa, seems pertinent. Endings are something I struggle with in general and I find therapeutic endings difficult in particular. They don’t follow the same rules as ‘normal’ relationships which end when they go bad or when they no longer gratify whatever need they were supposed to. Good relationships don’t end. Therapeutic relationships are different.   


I recently ended with a patient I’d become very fond of, who had been coming to see me for four years. I’d spent about half that time wondering when we should end. Whenever I considered ending, something got in the way; either external issues – his, or internal dilemmas – mine; ‘how could I abandon him?!’ And then something changed. The adolescent boy in the therapy room regressed into the little boy I’d met years earlier. I became aware of re-emerging themes I hadn’t seen since his early sessions. It felt as if he was leading me back to the beginning. 

I was reminded of a poem which was read aloud towards the end of my training by a favourite tutor in her rich Irish brogue. The poem was T.S. Eliot’s ‘Little Gidding’ and the quote I was reminded of is this: ‘What we call the beginning is often the end. And to make an end is to make a beginning. The end is where we start from.’


My ending with the client, like the poem it brought to mind, was quite beautiful. It reminded me that therapy, like writing, is a creative process which is often beyond control and may never feel fully complete. Both follow themes and boundaries, such as time/word count, but they must also be allowed space, because nothing stifles the creative process more than rigidity. And so, I will continue to challenge supervisors and commissioners (and frustrate editors) as I wait for my endings to come. 


(First published in BACP Children & Young People December 2011)

Lies all Lies

(First 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. 


References

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