The following article is written by Brighton Therapy Partnership trainer Rebecca Kirkbride, and looks at the challenges of working with risk with young people. This topic will be explored in further detail in our upcoming workshop, Walking a Tightrope: working with risky behaviours in adolescent clients with Rebecca.
Young People and Risk
As a practitioner who has always worked with both adults and young people, I am fascinated by the areas where therapeutic work with these groups differs. Exploring and understanding these aspects of the work was the focus of my first book, Working with Children and Young People in Private Practice: A Practical Guide, which dealt with the particular challenges of working with children and young people in private practice, rather than adults.
Risk-Behaviours in Young People
One area that the book dealt with and which I see as central to much of the therapeutic work undertaken with young people, is that of working with risk and with ‘risky’ presentations with adolescent clients.
Most of us whose practice includes work with this group will have experience of working with clients who present with risk-related behaviours, such as eating disorders, substance misuse, self-injury, anti-social behaviour, sexual behaviour, online activity involving risk, amongst many others.
While it is not uncommon to find ourselves working with young people with such issues, it can be difficult for even experienced practitioners to know when what the client is bringing to their sessions has crossed over from being an issue which can be contained and explored within the therapeutic relationship to something possibly indicating that the young person is at risk of significant harm and therefore requiring further intervention, possibly involving breach of confidentiality.
Breaking confidentiality is generally a tough call for practitioners to make and it can have a considerable impact on the therapeutic relationship, so it is vital that practitioners have the best possible understanding of risk-behaviours and presentations, as well as good support from clinical supervision when managing such decisions.
Confidentiality, Risk and Age
Risk is something that all practitioners need to consider when working with a client, whether an adult or a child or young person. However, the way we work with issues of risk or risk-behaviours will differ considerably depending on the age and/or mental capacity of the client.
A young person under 16 years of age may or may not be considered to be ‘Gillick’ competent, i.e. as having sufficient understanding to make decisions about their health care without their parent or carer(s)’ knowledge or consent. If they are considered ‘Gillick’ competent then they have the same right to confidentiality in their counselling as an adult and therefore the same right to what they reveal in a session being treated confidentially, depending on the limits of the confidentiality as defined at the start of the therapeutic relationship. This might mean there is an expectation for the client that if they talk about self-injury or substance misuse in a session this will not automatically be shared with parents or teachers etc. unless there is a risk of significant harm.
Guidelines for safety
While this can be beneficial therapeutically as it means that these issues can be explored and addressed safely in a secure therapeutic relationship, it also leaves the practitioner having to make tricky decisions about any potential risk of significant harm arising during the course of the work. For counsellors working in educational or agency settings, these limits are usually set out in organisational protocols on safeguarding, as well as in current government guidance on the subject.
Counsellors working in private practice are not officially covered by such guidance and need to draw up their own practice guidelines on safeguarding in line with their ethical framework and relevant laws.
Risk is an important area for us as practitioners to be aware of and feel confident in working with, in order that we can offer clients the best possible opportunity to work through complex issues, whilst also keeping them safe where possible.
For young people who are engaging in risky behaviours, there are often deep-rooted issues underlying the behaviours which need to be attended to and carefully explored within a solid and boundaried therapeutic relationship. If the limits of confidentiality are outlined clearly at the beginning of the counselling, whether or not it seems that risk is an issue, it can be easier to go back and look again at these established limits if and when issues of risk arise in the work. Risk assessment is a crucial part of working with young people and practitioners need to be prepared to assess for presence of risk factors and for their severity on an ongoing basis throughout clinical work.
Risk is an aspect of a young person’s presentation which can alter rapidly during the course of counselling in either direction, as shown in the following brief case example…
Case Example: Rose and Maya
Rose is a thirteen-year-old girl being seen in private practice by Maya, an experienced counsellor.
Rose was initially referred for counselling by her mum who had concerns about Rose’s ‘fussy-eating’. At the assessment, Rose talks about feeling anxious about eating certain foods which she believes are ‘bad’ such as flour and sugar. She insists she wants to be ‘healthy’ and is not bothered about being slim. Having now met with Rose on two occasions, Maya is concerned that she is displaying the early signs of significant eating issues which could develop into an eating disorder. Despite being slim and of slight build, Rose talks about being much bigger than her friends at school and is convinced that she needs to lose weight in order to be able to dress the same and ‘fit-in’ with the group.
As their sessions continue, and the therapeutic alliance develops, Maya learns that Rose often throws her packed lunch away when she is at school and is increasingly having powerful negative thoughts about being fat and lazy, which she finds hard to ignore. She also feels compelled to exercise whenever possible.
At this point in the work, Maya decides that Rose’s issues are more serious than just fussy-eating and that her parents need to be aware that there is the risk of an eating disorder developing. Maya and Rose discuss bringing her parents in for a session to discuss this and, although Rose is reluctant at first, she agrees that this is something she is struggling to manage outside of her sessions with Maya. Maya and Rose begin to explore how best to bring her parents into the work and what she is and isn’t happy for Maya to share with them.
Risk and adolescent development
So far we have looked only at the negative aspects of risk in work with adolescents, but there is also an important positive role for risk to play in child and adolescent development.
In my own practice working with young people, I have become increasingly interested in the role that risk and risk-taking plays in this development and particularly in the process of separation and individuation which is a vital aspect of adolescence and the transition to adulthood. Just as the toddler must face uncertainty and take the risk of standing up on wobbly legs and attempting to walk across the living-room, so adolescents need to be able to take appropriate risks in order to find out what they are capable of as individuals and to gain confidence in these capabilities. Young people who are unable to take such risks often find themselves struggling with various aspects of separation and individuation such as going away to university, or living independently of their parents.
Paradoxically, clinical work with this group can sometimes be as much about encouraging the young person to take appropriate risks vital for the transition to adulthood as about helping them to understand and manage risk behaviours in order to prevent them coming to harm.
For more on this topic, join us on 23rd September for our event on adolescents and risk.