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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