News

Just before seeing a seven-year-old girl, I doubted that she would benefit from therapy. She had been through several placements, and there were clear issues that needed addressing in her new placement and at school, to prevent further moves. So, what made me change my mind?

Despite the changes around her, she appeared able to make connections between her traumatic experiences, her feelings and her behaviour. But is this a conditional or sufficient indication for individual therapeutic work?

More important, can it predict future benefits from such an intervention? This is quite a common dilemma in clinical practice, whatever the client's age.

As it's a widely used term it might be useful to set out very briefly what "therapy" means. Psychotherapy enables an individual to make sense of their experiences and impact on their emotional (inner) world, and on the way they function or behave.

The broad principles are often identified with specific theoretical frameworks, therapy schools or techniques. Long-term (usually analytical) therapy helps the child re-enact previous experiences through their relationship with the therapist ("transference" and "counter transference").

In psychodynamic therapy the understanding of previous experiences is important but there is more focus on the "here and now".

Less active approaches such as counselling and supportive therapy can be more beneficial for young people with either existing coping strategies or those who wish for some therapeutic space to reflect and strengthen their existing resources.

Even the boundaries from other therapies aiming at changes of thinking patterns (predominantly cognitive-behavioural, but also solution-focused therapy) are not as clear cut as once thought, particularly as applied therapeutic interventions are often not "pure", but rather cross theoretical boundaries.

A number of other factors will determine whether it is appropriate to refer a child or young person for therapy. Some of these are pragmatic, such as the local availability of therapeutic resources, therapists' workload and the level of service.

Another contentious issue has been the degree of "stability" required before therapy can start. The increasing application of therapies for vulnerable young people and their integration into the care plan should help resolve this debate, and rather focus on what is more appropriate for a particular child at this time of their life. Moving between placements should not be a reason not to consider therapy.

Ultimately, one needs to remain open to the child's signals of distress or wish for help, hence my ambivalence and change of mind after meeting this strikingly insightful seven-year-old child.

Panos Vostanis is consultant child and adolescent psychiatrist with the Leicestershire Partnership Trust's young people's team, and professor of child psychiatry at the University of Leicester.