When it comes to counselling, understanding your client is key. Young people are often in a very different mental space than adults, due to the physiological and cultural specifics of adolescence.
Brighton Therapy Partnership explored this topic at an event with Rebecca Kirkbride – an experienced therapist, working with both adults and adolescents in private practice. She gave a talk and workshop with BTP on the dilemmas of working with young people in private practice, and gave some suggestions of how to work with these dilemmas in mind.
Rebecca Kirkbride returns to Brighton Therapy Partnership on Saturday 2nd February 2019 with her new workshop on *Only Connect: Building effective relationships with young people in therapy* where Rebecca will look at how to best understand and develop a positive working relationship with young people and teenagers in therapy.
What happens in adolescence?
As a child grows into adolescence, he or she experiences a huge amount of change. Puberty is a time when the body is rapidly growing and changing and young people start to be more aware of their sexuality.
There are psychological changes, such as changes in attachment to their parents and cognitive growth. This has a huge impact on adolescents emotionally, and can be very distressing, so it can be extremely beneficial for a young person to come to therapy to explore their feelings with an adult who is not their parent or carer. Working with adolescents can be extremely clinically rewarding, yet it does throw up challenges for the therapist. We are going to examine three dilemmas that regularly occur in these scenarios.
The dilemma of parental involvement in counselling
When an adolescent comes to see a private therapist, it is very likely that there will be some level of parental involvement in the process. A referral will generally come from the parent (especially if the adolescent is under 16). This means that the parent will have to agree to their child having a confidential relationship with the therapist (which the parent will be to some extent excluded from). This means that it is important for the therapist to build a rapport with the parent, and to enable the parent to be more supportive of the process. It can be threatening to a parent to have their child talk to somebody else, so it is important that the therapist tries to make the parent feel at ease. After all, the parent is usually the one paying, and they can choose to cut the therapeutic ties at any time.
The therapist needs to consider whether they will meet with the parent face to face or whether they will have an initial information gathering session over the phone. It helps to have some communication with the parent in order to help give the parent an idea of what they are committing to. If the parent is the one paying, then the financial contact needs to be made with them. The best approach is to have two separate contracts: a financial and practical contract with the parent, and a therapeutic contract with the adolescent.
It is important that there is communication with the parent regarding confidentiality so that the parent has an understanding of the process. This enables the parent to have more understanding of the young person’s needs. One way of doing this is by offering an information sheet with information about confidentiality. Alternatively, the therapist can offer an initial face to face or telephone session with the parent, to explain what counselling is, and what the parent can expect.
It is important to have transparency with the parent around confidentiality, and to let them know that you will be transparent with the young person about any contact you have with the parent after the therapy has started. This helps protect confidentiality.
There can also be a use for family sessions, where the parent is brought into the process. This should only happen if the therapist feels confident in this and needs to be consented to by the child. Time needs to be given to properly process what happens within these sessions.
All family contact in the therapy must have the wellbeing of the child as the focus. It is possible to get into the dynamic where we are caring for the parent. Remember who your client is!
The dilemma of confidentiality and consent
Confidentiality is of great importance in any therapeutic relationship. However, this becomes more complicated when working with adolescents. The BACP states that careful thought needs to be given when working with young people as to their capacity to give informed consent to a confidential relationship (sometimes referred to as ‘Gillick Competency’).
It is important that, when working with any child or adolescent, the counsellor can asses whether the young person has sufficient understanding of what they are agreeing too.
Consider the following:
- Can the child understand the question being asked of them?
- Does the child have a reasonable understanding of…
- What information might be shared
- The main reason or reasons for sharing information?
- The main implications of sharing that information, and not sharing it?
- Can the child or young person:
- Appreciate and consider the alternative course of action open to them?
- Weigh up one aspect of the situation against the other?
- Express a clear personal view on the matter, or are they constantly changing their mind?
Once these points are considered, the therapist can make a decision about whether this young person is suitable for therapy. It is okay for the therapist to refer on if he or she does not feel she has the skills to work with a particular young person. It is better to know your limitations.
The dilemma of working with risk with young people in private practice
With adolescents, risk starts to emerge in a heightened form compared to working with children. Adolescence entails that young people start taking more risks in terms of drugs and alcohol, sex, and risky behaviours. Adolescence can also bring the first instances of suicidal thoughts, eating disorders and self-harm.
We need to be aware of risk when working with adolescents and know where our boundaries are in terms of confidentiality. A young person is likely to lose trust if their therapist overacts about a risk that the client does not think is significant. However, it would be dangerous to not pick up on a risk that might cause significant harm to the client.
Remember, in private practice you are not held by an organisation that will deal with risk for you, so you need to have your own protocols in place that are informed by the following:
- Contracting – limits of confidentiality. Establish a clear contract with the young person with the limits to confidentiality clearly set out. This will help the young person to feel the boundaries of what they know they can tell you in confidence, and what will be taken further
- Supervision – discuss any potential breach of confidentiality in supervision in order to fully explore the possible consequences for the young person, and the therapeutic alliance
- Significant harm – be clear about what constitutes significant harm (see the Children Act 1989)
- Public interest – be clear about what constitutes public interest and when to consider this in terms of risk.
For more information about risk, Rebecca recommends looking to Tim Bond’s writing on ethics in counselling.
Essential points on counselling young people:
- The parent will usually be involved in the therapeutic relationship in some form, so remember to create a rapport with the parent (but not at the expense of the relationship with the client)
- Children and young people might not have the capacity to consent to a contract that you would give to an adult client
- You need to consider the implications of working with risk with adolescents, and have clear boundaries and protocol around how you deal with risk