My Practice

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

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.

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