Child and Adolescent Psychotherapy in IAHIP: A Personal Viewpoint

By Eileen Prendiville

Is there a place for Humanistic and Integrative Child and Adolescent Psychotherapy in IAHIP?  The question of whether IAHIP is an organisation for psychotherapists who practice with adults only or for those working with clients throughout their lifespan is a big one. Is the important point the age of the client or the orientation of the psychotherapist?

IAHIP has clear policies and bye laws that address issues like accreditation, training, codes of ethics, etc. and yet the question of who our clients may be is not so clear: I can find no mention in any of the documents to address this question. In fact I can find no references anywhere, including within our Memorandum and Articles of Association, to the age of the clients who may be served by our professional members. Perhaps it is time to take steps to ensure that members who undertake such work are adequately trained for it as, like adult psychotherapy, it is a complex area involving deep work with vulnerable clients.  However, until, and unless, we answer the question in relation to the client groups we serve, it is difficult to set and enforce standards for those practicing with this, and other, specialized groups. Maybe it is also time to ascertain if there is a shared viewpoint in relation to client age groups to which the majority of our members subscribe.

The issue of child and adolescent psychotherapy has been seen as a key issue at European level for over two years now and has generated extensive debate and discussion.  Children and adolescents have been attending psychotherapists from a variety of modalities (and practitioners with all ages of clients have been awarded the European Certificate of Psychotherapy) and yet, other than the generic TAC standards, no clear position has existed in relation to the essential training components for this work. Many IAHIP accredited psychotherapists, and some pre-accredited members, currently practice with children and adolescents: 74% of those who responded to the questionnaire on this topic, circulated to members in Oct 2007, said that they were currently, or had been in the past, engaged in such work. This questionnaire looked at the age bands of members’ clients, and very briefly at any relevant training, separate to adult oriented psychotherapy training, that these members had undertaken to equip them to see such clients. See box below for some interesting findings in relation to this group of respondents:

• More than 77% had undertaken specific training that they considered relevant. This included associated professional qualifications held by more than half of this sub-group (teaching, nursing, social care, social work and clinical psychology).
• Almost half had attended specific child psychotherapy, play therapy or creative arts courses, including 7% who had undertaken child psychotherapy as their core or dual training.
• Almost 60% attended relevant CPD events (play therapy, creative arts)
• 27% of the full group who had engaged in this work had no specific or relevant training
• 20% of those with some relevant training had only attended short workshops or in-service events

Present Position

At present IAHIP have no recognized Child and Adolescent training courses. However, all core training courses are required to have a substantial experiential component and this learning contributes to the personal development of the trainee. This approach is designed to bring the ‘trainees to a level of competence where they are able to facilitate client’s work at a deep level of awareness and understanding’. This focus on the person of the therapist is beneficial regardless of their future client group. Many courses utilise action methods and the use of creative media and interventions in their groupwork sessions. The use of clay, art, drama, music, voice work, movement, dance, sculpting, sandtray work, creative visualisation, relaxation techniques, storytelling, and ritual etc, in personal development work, and in the experiential learning of skills and theory, is all beneficial training for the therapist who may use such approaches with their future clients. Such learning, in addition to the personal therapy element of training, the clinical practice under supervision, and the core theory and skills associated with the practice of psychotherapy from a humanistic and integrative perspective, are central to the training process.

Categories of Psychotherapists

It is clear that the process of psychotherapy with adults is not the same as that with children and adolescents and different knowledge and skills are required. Much of the content in core trainings is however, relevant to children, adolescents and adults (e.g. theories of human development, psychotherapy approaches, theories of change, social issues, life span development, theories of psychopathology, professional issues), and the personal therapeutic experience elements (personal therapy, groupwork, self reflection, journaling etc) which contribute to the personal development of the trainee would be of benefit to all practitioners.

However, to work in a specialized area requires specialized training. While the therapeutic relationship remains central and the availability of the therapist for a genuine, congruent relationship may still be the most important element, this must be complimented by competence in specific areas that should include developmentally appropriate skills and theory. The child’s lack of independence and need for security and protection in the lived world needs to be recognized as playing an important part in determining the child’s readiness to engage in a psychotherapy relationship, and the need to work in partnership with carers and guardians is critical. The use of developmentally appropriate approaches (including play) and materials is vital and a child-centred approach that takes account of the role of various members of the multi-disciplinary team that may be involved is also important.

It appears to me that there are at least three categories of humanistic and integrative psychotherapists:

• Those that undertake training in working with adult clients only
• Those that undertake training in working with child and adolescent clients only
• Those that undertake training in working with clients of all ages

Could there then be 3 TAC compliant options for Institutes offering Core Training?

1. Core Training to qualify graduates to work with adult clients only. Many such courses already exist.
2. Core Training to qualify graduates to work with clients under 18 as primary clients only – but trainees/graduates also need to be equipped to work systemically with child’s family and carers (as secondary clients) so the training course would need to cover skills in relation to this also. Such training already exists in the Psychoanalytic Psychotherapy section.
3. Core Training to qualify graduates to work with adult clients and with clients under 18 years (i.e. concurrently training for both groups). This is not a new idea: Family Therapists are currently trained to work with these groups and the Clanwilliam Institute offers TAC compliant training leading to the award of the European Certificate in Psychotherapy.

I do not think that there is anything to suggest that it should be necessary, or even desirable, for those who wish to work as psychotherapists with children to undertake a specific training in working with adult clients first (or vice versa). Perhaps it is useful to have separate, but inevitably overlapping, training standards in relation to the 3 categories of practitioners mentioned above. What we need to guard against, and set standards in relation to, is psychotherapists training to work with either adults or clients under eighteen years, and then undertaking practice with the other age band without adequate, specific training, and appropriate supervision with a supervisor who has expertise with clients of similar ages/stages of development as the supervisee’s client group. This means actually adopting some criteria in relation to core areas of training and subsequent accreditation.

If the three options above existed, it is likely that most trainees would still choose to train for working with adult clients only. Others would choose either the child and adolescent option or the concurrent training option, although dual aspect training would be likely to entail a greater number of training hours than either of the two other options.  Psychotherapists who undertake a full training course in working with a single category of client (i.e. adults or children), may later decide that they wish to expand their practice to work with the other age range and this raises the issue of looking at requirements for specialist training for qualified practitioners. Standards need to be set in relation to this ‘top-up’ specialist training, and appropriate supervised clinical practice. In relation to ‘post-qualifying’ courses, the UKCP have estimated that the duration of the skills and theory training would be approximately 200 hours; the clinical practice would comprise 300 hours plus clinical supervision. This training and practice would take place on a part time basis over a two year period.

Systemic and Developmental Considerations

Therapists trained to work with children still require a considerable emphasis on working with adults as secondary clients and on understanding lifespan development, the impact of parental clinical issues on children, and in understanding the impact of traumatic events in childhood on subsequent development. To work in a humanistic and integrative way, the child psychotherapist would inevitably need to work with the adults entrusted with the care of many of their child clients and in some cases the psychotherapist would work with the parent/carer rather than the child – particularly if the pre-therapy considerations (especially in relation to safety) have not been met for the child. A significant aim of child psychotherapy practice is to empower supportive (and non-abusive) parents and carers to play an active and central role in the child’s recovery and healthy development.

Trainees attending a concurrent, dual aspect, training would benefit from the focus on working with clients throughout their life span as primary clients and would be likely to have an in-depth understanding of the impact of life events on the developing child and the arising difficulties that may well continue to impact on adult clients. This may result in them being particularly alert to working with related issues of distorted/interrupted development. Many of our adult clients have unresolved childhood experiences that they wish to address in their therapy process. An in-depth understanding of child development can only enhance our practice. Words are not the primary method of communication for children and I do not believe that they can become so for the adult that is dealing with early childhood issues. The focus on developmentally appropriate practice that is central to child and adolescent training can be a real benefit to those working with adults also, especially when dealing with issues that occurred during the pre-verbal stages of development and in therapy with adults with special needs, brain injuries, etc. Creative approaches can be beneficially utilised with clients of all ages, abilities, and life stages. Recent neurobiological research clearly shows us that activities that involve the right brain will be particularly effective in developing new brain pathways and facilitating connections between the upper and lower brain; this can result in more effective coping and affect regulation. Creative approaches also impact on chemical activity in the brain, relieves psychological pain and contributes to the release of opiods and oxytocin, thus giving some relief from the effects of too much acetycholine which is associated with anger and hostility.

Points to Ponder:  Standards and Questions

IAHIP have, rightly, adopted stringent standards and criteria for the training and accreditation of psychotherapists. We have a transparent accreditation procedure to ensure that members becoming accredited meet these training standards.

I believe it is commonly accepted that IAHIP accredited members work with clients throughout their lifespan and that they do so under the auspices of their IAHIP accreditation. We have had many articles in Inside Out in relation to young clients.

Should standards be set in relation to this work?  Should it be covered under general accreditation? Should members be required to have a separate accreditation for this work? If so, should this be within IAHIP or outside of it?  It seems to me there is a lot to think about and discuss.

Is there a place for Humanistic and Integrative Child and Adolescent Psychotherapy in IAHIP? Is this a new question?

It is new to me that the question is being asked; until recent times my own perception has been that IAHIP did not differentiate between members working with clients of different ages as long as such practice was in accordance with the Code of Ethics. This may have been a mistaken belief. However, I am certain that it is not new for IAHIP psychotherapists to work with young clients. I have been involved in delivering this training to qualified therapists for over ten years and am aware of many graduates who are engaged in wonderful humanistic and integrative psychotherapy work with young clients. Many children and adolescents have been assisted to overcome traumatic experiences and deal with complex emotions and behavioural problems because of the availability and skill of such psychotherapists. Any of these therapists who are still pre-accredited are now prevented from counting these hours of practice as part of their post course practicum. Until recent months, the application for accreditation did not specify that only sessions with adult clients could be counted in the post-course practicum, regardless of whether the applicant has undertaken specific psychotherapy training for this work or not. My own essay, as part of my application to IAHIP for accreditation, had 3 main paragraphs: my philosophy, my work with child clients, and my work with adults. In the second section I openly discussed my client group, who were aged from three years of age, my approach to the work, and the context in which this work was placed. I know that I am not the only successful applicant who worked with children and adolescents prior to accreditation.

It is also clear that a significant number of IAHIP members are engaged in psychotherapy work with children and adolescents; it is expected that such members work in accordance with the IAHIP Code of Ethics and Practice, section. Our Code of Ethics covers issues of competence, section 8.3 is concerned with the duty of psychotherapists not to work outside the limits of their competence and to recognise if they have insufficient training or experience to work with a specific client and refer onwards if indicated, section 3, Issues of Responsibility, includes reference to obtaining consent from guardians, and section 6.5 compels the psychotherapist to work in accordance with the Child Abuse Guidelines and be informed of the current legislation.  Unless it is suggested that members who work with young clients are in breach of this Code, we are accepting that members engage in this area of work safely and ethically.

Conclusion

As far as I am aware, no IAHIP documents (Memorandum and Articles of Association, or Bye Laws), state that IAHIP was/is only intended to be an organization accrediting those who work with adults and I am concerned that the stance of excluding child clients/practitioners who train to work with children and adolescents, was not always in place and seems to have crept in without ever being voted on or adopted as a policy.  I believe that it is not problematic that hours working with children have in the past been included in successful applications for accreditation, but I am concerned that some applications may now be refused on this basis without this being a written policy that the membership has voted on.

Perhaps it is time to see if there is a viewpoint to which the majority of our members subscribe so that if new policy is to be adopted, the associations’ documents can be updated to reflect this policy.

Likewise, if IAHIP practitioners are to work with clients under 18 we need to set appropriate training and accreditation standards to protect clients and support members in this work.

Eileen Prendiville EAP, MIAHIP, IBECPT, CPT-P, RNM. H DIP. Ed is a Psychotherapist and Play Therapist. She is trained in Humanistic and Integrative Psychotherapy, Jungian Sandplay Therapy and Biodynamic Psychotherapy and has over 30 years experience in working within clinical settings and the community, with adults, children and adolescents. She is Director of the Children’s Therapy Centre, Ireland’s foremost provider of Humanistic and Integrative Child and Adolescent Psychotherapy and Play Therapy courses. A range of play therapy, creative psychotherapy, and supervision training are also provided. Further information from www.childrenstherapycentre.ie, childrenstherapycentre@gmail.com