Child and Adolescent Issues in Psychotherapy

by Eileen Prendiville

Trauma and other adverse life circumstances impact on children in ways
 that restrict their ability to engage fully with the world. Development is 
interrupted – any experiences that cannot be assimilated must be
 accommodated to. The development of a physical and emotional sense of
 self is interrupted and the young person may not develop the ability to 
empathise with others and form healthy relationships. If the child has been
 mistreated or abused they may continue to respond to the world as if it were
 a dangerous place even after their safety has been secured. This all
 contributes to significant difficulties, e.g. with boundaries, that need to be 
addressed in creative ways, so that the child or young person can begin to 
live in keeping with their current reality.

Traditional ‘talking therapies’ do not meet the needs of children – the 
language of childhood is play. Non-directive play sessions provide the ideal 
starting point for therapy with young clients. The recurring themes in their
 play will highlight the child’s confusions and stuck points and their 
projective play provides a window into their inner world that enables us to
 better understand their worries and needs. Child centred therapy facilitates 
the client in connecting with their core, creative self. It involves the use of
 creative techniques and media and takes account of the young person’s 
developmental level, dependency, and emerging needs. The use of play 
therapy, sand play therapy, projective techniques, therapeutic stories,
 creative therapies, and sensory stimulation are central and an understanding
 of the developmental play model assists the therapist in ‘reading’ the child’s 
non verbal communications. As with all therapy, the therapeutic relationship
 and the safety provided by the structure of the therapy itself makes it safe 
for the child to engage in the process, explore their life experiences and
 feelings, and risk new ways of being in the world.

Young clients are different to adult clients in many ways, the most 
significant of which is their naturally dependent status; they need others to
 take care of their needs for safety, protection, and basic care. Children need
 adult help, support and care to assist them in negotiating the world. They 
lack the maturity, the access to resources, and the capacity to utilise services 
without the assistance of an adult.

The younger the child the smaller their world is. They are introduced gradually to an expanding world as they grow and engage with the extended
 family, community, schools, and wider world. Emotional development is 
shaped by parents’ capacity to successfully contain the child’s emotions, sensations and distress. Ideally, the child should experience the satisfaction of having their needs met by their caretaker. The parent’s ability to attune to 
the child and successfully provide this containment will impact on the
 child’s potential to tolerate and master difficult sensations and make sense of their world.

Young clients, from pre-school years to the cusp of adulthood, must be seen
 and met in the context of their family and the wider community. They are
 still in the process of becoming. The young client needs others to support 
their healing. In therapy clients become more aware of their vulnerability,
 defences loosen; they start to see their world as it truly is. The ego develops,
 the client becomes more adept at evaluating experiences, contradictions are
 highlighted, and core beliefs are explored. This presents challenges, and 
invites the client to abandon old ways of being and take risks in trying new
 roles and behaviours. This is too much for a child/teenager to tackle without
 adult support.

Therapy work with child clients is more complex than similar work with
 adults. While both possess the potential to direct their own healing, adults 
have more power both in the therapy relationship and in shaping their world
 outside therapy. They can take responsibility for instigating change; can 
make independent choices in regard to their living arrangements, personal 
relationships, and personal safety. They have life experiences that enable
 them to reach fuller understandings of the dynamics of their own
 experiences. They have awareness of the systems in place (legal, medical)
 to support them if needed. Of course even adult clients are often not ready 
yet, to make the changes they may subsequently choose, they benefit from 
the support of the therapeutic relationship to take the risks they deem 
desirable in their lives. Children and young people also benefit in similar
 ways. However the resources available to the adult (life experience,
 knowledge, power, choices) are not available in the same way to the young 
client. They cannot, for example, secure their own protection, choose their
 caregivers, their home, or their school, or access legal assistance to instigate 
changes in their lives. They need the help of an adult to support them in their 
healing and take responsibility for ensuring that their basic needs for food,
 heat, safety and protection are met before the child can engage fully in 
therapy.

Before engaging in therapy with a child/young person it is essential to learn
 about them and their situation. The family will not be able to support the
 child’s development or healing if they have serious unmet needs of their 
own. Having relevant information to hand about their home life and living 
arrangements helps ensure that interventions do not serve to make the child
 more vulnerable or susceptible to harm or unnecessary distress. It will help 
in planning intervention and evaluating if adequate supports exist to make 
therapy a viable option. The time may not be right, a different intervention 
may be more suitable e.g. an abuse investigation, a medical examination to 
rule out possible physical problems, family therapy etc. It may be necessary 
to delay starting therapy until the pre-conditions can be met. The parents 
may be the initial focus for intervention.

No one individual or agency can meet the range of needs that emerge when 
working in a child-centred way. Multi-disciplinary teamwork and working 
in partnership provides greater opportunities for effective intervention with
 vulnerable families. This broad-based approach to work with children helps
 ensure safety, and effectiveness. Therapists who work with children in 
isolation are often frustrated in their work and find that the child gets ‘stuck’
 or cannot move forward because the bigger picture is not being seen or 
addressed. Children and young people cannot be given responsibility for 
changing their world – only adults have that power. Likewise, the child or 
young person should not be expected to take risks in a vacuum – the safety
 and containment that exists in the therapy room and relationship needs to be 
extended to their world at large. It is essential that the child is not being 
undermined or abused if they are to be able to benefit from the process of 
therapy.

The therapist is responsible for all safety and boundary issues in relation to 
the therapy and for providing the optimum environment in which healing 
can take place. At the most basic level this includes ensuring that the 
therapist is adequately trained and competent for the work involved. 
Specific training in child psychotherapy, play therapy or creative therapies 
is an advantage. Personal therapy, ongoing professional development, 
ethical work practices and supervision need to be given priority.

The building of a therapeutic relationship is dependent on both the client
 and therapist mutually agreeing to engage in therapy. We can not ‘slip’
 therapy into children without their knowledge or consent, or ‘do it’ to
 children without them being an equal partner in the relationship and making 
a clear contract or agreement in regard to the work. Limits to confidentiality 
- for example where issues of child safety are raised – must be made clear.

Child-centred mediums and approaches

A child is not a small adult. This simple fact impacts on all elements of our
 work with children, yet it is often ignored and leaves children feeling 
unseen and unheard and results in frustration for the workers involved. Play 
is the language of childhood and is the primary medium for communication.

Speech can only be a second, less expressive medium. The child cannot
 utilise their full potential for self-expression if we restrict their use of play
 and thus prevent true creativity and spontaneity. To work in a non-directive
 child-centred way means abandoning our traditional ways of
 communicating – speech is only second best, asking questions is outlawed, 
judgmental comments, even praise, are banned, our own agendas must be 
thrown out, and we must share power while holding responsibility for the 
safety of the child, the therapeutic relationship and ourselves.

One of our aims is to ensure that the person the child meets most in therapy
 is themselves, the more space the therapist takes up in the process the less 
space that is available to the child. The therapy room itself is important. Its 
size, furnishings and equipment (toys, art materials, creative materials, sand
play therapy supplies and other resources) must be considered from the
 perspective of the clients. Materials should be chosen to assist the young
 client in self-expression and facilitate embodiment, projective and role-play.
 This will facilitate the client in directing their own healing and
 strengthening their physical and emotional senses of self and exploring their 
own and others roles in their life.

In summary, play therapy seeks to provide a therapeutic space for children
 to use in a way that meets their needs – to express emotions, explore life experiences, experiment with new ways of being, and, perhaps, gain insight
 into their realities. The space is made safe by the presence of a non-
judgmental, attentive, accepting adult who accepts and respects them just as 
they are. The child chooses whether to engage in therapy or not, and sets the 
pace and direction of the sessions. The therapist ensures that safety issues
 are never compromised. Increased awareness and healing can take place
 within the context of the relationship that develops between the child and
 the therapist. The worker can reflect back the child’s words, the content of 
their activities, or the feelings expressed in their play. Empathic listening is
 central. A focus is maintained on both verbal and non-verbal 
communications. This helps to intensify the child’s experiences, facilitates 
increased awareness, and gives the child the experience of being witnessed 
- both seen, and heard in a holding relationship. Symbolic play is not
 interpreted to the child. Symbolism and metaphor enable the child to
 explore issues in a safe way, and to direct the course and pace of the therapy 
according to their needs.

Younger children are more inclined to resolve issues on a sub-conscious
 level, to engage in less direct conversation, and to address their difficulties 
through symbolic mediums – therapy need not be insight based. The healing
 can occur within the metaphors of the child’s play. Change occurs at the
 core of the personality. A lot of therapeutic play evolves around physical
 activity, story-making and exploration of roles. For the pre-school children
 in particular, play will develop around themes connected with home life and 
fairy tales. Slightly older children will incorporate their experiences of
 school into their play. Pre-teens and adolescents will be attracted by 
opportunities for dramatic play, creative therapies and therapeutic board 
games. The ‘self’ develops: self-esteem, self-image, self-efficacy and self-
confidence will all be enhanced.

The child cannot be seen in isolation. Their family – both caregivers and
 siblings may benefit from support, information, advice, counselling or
 therapy. Groupwork or individual work may be appropriate to meet their 
needs. The child’s therapist needs to have a link to the caregivers either
 directly or via another professional. The care-giving parent is generally the
 most important person in the child’s life and must feel respected and
 included in the work with their son or daughter. They have enormous power 
to assist (or sabotage) the child’s healing. Effective therapy empowers the 
caregiver in providing a broad therapeutic environment for the child outside 
of the therapy settings. Traumatised children need more than a one-hour
 therapy session every week. The other 23 hours are vitally important also!
 Caregivers can provide opportunities for developmentally appropriate play,
 creative expression, sensory experiences, positive relationships and
 containment for the child or young person. The world needs to become 
predictable to the child and they need to experience safety and security. The 
home is a good place to start.

Conclusion

Therapeutic work with children and young people is very different to work
 with adults. The child does not have the independence, maturity, life
 experience and ability to take care of their own needs for safety, nurturance, 
education, and support. However, given a supportive environment, child-
centred approach, and a strong therapeutic relationship, all children, like
 adults, possess a striving for wholeness and the potential to heal themselves
 and recover from any traumatic experience.

Eileen Prendiville is Clinical Director of The CARI Foundation and is core
 trainer on CARI’s Child Psychotherapy Training Course and therapeutic 
play workshops.