Child can veto consent and if the counsellor

Child therapy is “assisting the child’s quest for strength and self-support” (Oaklander, 2007, p.74). This essay attempts to shed some light on this process. Ethical considerations and the central role of the therapeutic relationship will be discussed. An overview of theories of human development will be reviewed and the process of assessment will be considered. The Sequentially Planned Integrative Counselling for Children (SPICC) model will be discussed, followed by a discussion.1     Ethical considerations in working with minorsWhen working with children and adolescents, the dignity and needs of the child are prioritised and care is taken to do no harm to the child and that the counsellor is competent. It is the responsibility of the counsellor to work with integrity, to be self-aware and to receive supervision (“IACP Code of Ethics”, 2018).1.1    ConsentBoth guardians’ consent is required when providing counselling to a minor; the counsellor needs a declaration of consent signed by both guardians. Either guardian can veto consent and if the counsellor leaves one guardian out, the counsellor could be accused of parent alienation. If a child is not under the care of the parents, the counsellor must find out what the Care Order is to know who is to give consent, as well as to understand the stability of the child’s situation and to establish what kind of supports the child has in her life (Health Service Executive, 2011). 1.2    Confidentiality and Child ProtectionThe child is the client and what happens in the sessions is strictly confidential (“IACP Code of Ethics”, 2018). This is explained to the child in her own language, as well as the situations when confidentiality cannot be maintained (Health Service Executive, 2011; Department of Children and Youth Affairs, 2017). The counsellor emphasises that the sessions are private, but not secret. In case of disclosure of abuse, and breaking of confidentiality, it is important that the counsellor keeps the relationship with the child and does not abandon her (Malloy, Brubacher & Lamb, 2011), and focuses on the child’s coping skills.2    Therapeutic RelationshipThe therapeutic relationship between counsellor and client, is the most important factor in therapeutic outcome (Geldard & Geldard, 2008; Mearns, Thorne & McLeod, 2013).2.1    The relationship as a link between the child’s world and the counsellorThe relationship is a link between the child’s world and the counsellor (Geldard & Geldard, 2008). The counsellor should understand the way the child views and experiences her world, while taking care not to influence the child to change her views to be more like the counsellor’s. The counsellor should not judge, affirm or condemn the child as it expresses herself.2.2    ExclusivityThe relationship between the child and the counsellor is exclusive and no others, like the parents or a sibling, can intrude without the permission of the child (Geldard & Geldard, 2008). Confidentiality needs to be clear to the child and the parents. For the child it is important that the counsellor sees her the way she sees herself, and that the counsellor’s views of the child are not influenced by the views of the parents. Oaklander (2007) describes how she talks to the parents in the presence of the child, so the child knows what is said and doesn’t need to imagine what might be said. She also makes sure that she gives the child a chance to express her views and determines who has the problem. Sometimes the child doesn’t feel the reason for therapy is a problem, e.g. it could be the parent or a teacher who has a problem with the reason for therapy. The child feels heard and respected and can trust the counsellor.2.3    Safety and confidentiality in the relationshipSafety in the relationship is created by accepting the child without judgement and by not following negative consequences on disclosures of the child (Geldard & Geldard, 2008). There is the issue of breaking confidentiality in case of disclosure of abuse; it is important to be clear and transparent and give the child as much control over this process as possible. Boundaries and rules create safety: the start and ending of each session is on time. Axline (1964) describes how she explains to her child-client Dibs that the sessions end on time, and that this is independent from how he or anybody else feels about that. Dibs feels safe in this knowledge and this contributes to his growth.  There can be basic rules that the child can not hurt herself, the counsellor or damage property. If these rules are broken, the session is ended without repercussions and a new appointment is made (Geldard & Geldard, 2008).2.4    Authenticity of the relationshipThe counsellor must be congruent and authentic, and the interaction must be between two real people (Geldard & Geldard, 2008). The counsellor is not to play a role, so the child gets the opportunity to give up her false self and to express her true self. In this authentic relationship, emerging issues from the child are not avoided or suppressed, but are met in a genuine way, acknowledging the weight of the issues and dealing with them in ways that are congruent with the child at that moment.2.5    The relationship is non-intrusiveThe counsellor should take caution not to question the child in an intrusive way (Geldard & Geldard, 2008), but to respect the child in the amount she is ready to share and is able to cope with. A child’s resistance should be honoured and should be recognised as an important way the child protects herself (Oaklander, 2007). It is also important for the counsellor not to use information he has obtained from the parents or others; this would make the child feel unsafe, cause anxiety and could cause the child to disengage from the therapy. 2.6    The purposeful relationshipChildren participate better in therapy when they understand the reasons they are there Geldard & Geldard, 2008). Often the medium in child counselling is play: toys are used like words, and play is the language of children (Landreth, 2012). The counsellor must ensure play is facilitated in a purposeful way. This does not necessarily mean that play must be directed by the counsellor; opinions on the need for direction are divided. Axline (1964) is non-directive in her play therapy, while Oaklander (1997, 2007) directs children in a gentle manner. Geldard and Geldard (2008) contend that while non-directive play has its value, however, that if play in therapy is always non-directive, purpose is lost.2.7    TransferenceTransference occurs when the child sees the counsellor in the same way as she sees other significant adults in her life, especially the mother or father (Geldard & Geldard, 2008). There is positive transference when the child sees the counsellor as a nurturing parent, and negative transference when the child sees the counsellor as a critical parent. Counter-transference occurs when the counsellor experiences the child as if she is her son or daughter, and not a client. Counsellors need self-awareness and supervision to address their own counter-transference. 3    Theories of Human DevelopmentThe early pioneers of child therapy could be identified as psycho-analysts Sigmund Freud, Carl Jung and Alfred Adler. Freud theorised the unconscious processes and defence mechanisms. Anna Freud applied Freud’s theory to children by using the medium play and emphasising the relationship between child and therapist. Melanie Klein contributed with her ideas on transitional objects and Winnicott introduced the idea of the transitional space. Carl Jung’s work on symbols was used to interpret sand tray scenes, art and clay that children create in therapy; Margaret Lowenfeld was a pioneer on sand tray work (Geldard & Geldard, 2008). Alfred Adler, and later Bronfenbrenner, acknowledged the important role the environment plays in a child’s world. The environment can be viewed at various levels: home, community, larger society, the situation of war or peace.Abraham Maslow developed a theory of a hierarchy of needs (Atkinson, Atkinson, Smith, Bem & Hilgard, 1990). This is relevant to the child counsellor because if the more essential needs of the child are not met, the counsellor can not work effectively with the child and could do harm to the child. Lower level needs need to be met to some degree, before higher level needs can be met. E.g., the need for safety must be met, before work on self-esteem can be done.Erik Erikson described eight stages everyone must deal with in life (Atkinson et al., 1990). Each stage represents a crisis the individual must resolve in order gain strength. The counsellor needs to understand this theory to recognise the relevance in the counselling process and to assess adequately.Jean Piaget did elaborate work on the cognitive development in children. This theory is crucial to the counsellor to assess what a child is able to do and understand in therapy. Kohlberg added his theory of the development of moral values, which is highly relevant as a child’s decision-making process depends on where the child is in the development of moral values (Geldard & Geldard, 2008). John Bowlby’s (1988) work on attachment is very important in understanding the child and determining which interventions the child would benefit from most. Both Perry and Szalavitz (2006) and Van der Kolk (2014) describe the impact of attachment issues and developmental trauma, and suggest forms of treatment.Carl Rogers contributed the crucial role of a relationship between client and counsellor with Empathy, Unconditional Positive regard and Congruance (Mearns et al, 2013). Axline (1964) used his work in the context of play therapy and believed in the ability of the child to solve their own problems and was non-directive.Fritz Perls was the originator of Gestalt Therapy, a form of therapy that focuses on the here and now. Violet Oaklander (1978, 2007) adapted his theory to the work with children. She encourages the use of fantasy, believing that what comes out in fantasy play is a metaphor of the reality of the child’s experience of her life. When the child has created a scene of fantasy using a medium of e.g. sand tray, she asks the child how this scene fits into the child’s life. In that way she is directive. Oaklander is aware of the emotions a child carries and invites the child to express these emotions through play. Anger is one emotion she focuses on; children are often punished for expressing anger and it is important to acknowledge that anger is a normal human emotion and to express this emotion in an appropriate, safe way. Where Perls would challenge his clients when they resist, Oaklander respects resistance in the child as a necessary way to protect themselves, and does not challenge children.Foundations for Cognitive Behaviour Therapy (CBT) were laid by Skinner, Beck and Ellis. Skinner developed behaviour therapy using operational conditioning. Beck, Ellis and Glasser recognised that thoughts influence emotions and behaviour, and helped clients to change the way they interpret events in their lives and change their core beliefs (Geldard & Geldard, 2008). Narrative therapy was developed by White (2007). He separates the person from the problem and by doing this externalises the issue and makes it more manageable. Stories, or narratives about the child’s life are central; alternative narratives are developed, providing more helpful thoughts and core beliefs to the child. CBT is currently frequently used (Stellard, 2005) as a directive and short-term intervention. A limitation is that it is only suitable for children who have the cognitive ability to reflect on their thoughts and that only the cognitive part of the child is regarded, and not the child as a whole. CBT can be effective for children with trauma. Psycho-education is necessary to help the child self-regulate, e.g. by breathing exercises (Malchiodi, 2015). Geldard and Geldard (2008) developed an integrative model called Sequentially Planned Integrative Counselling for Children (SPICC), where different approaches are used at different stages of the therapy process.4    AssessmentTo use the time in therapy most effectively, the counsellor needs to gather as much information as possible about the child (Geldard & Geldard, 2008). The child may be referred by the parents or by a professional. Their experience of the child is valuable information, even though the counsellor may be of a different view. The counsellor establishes level of maturity in the child, chooses a suitable medium for therapy and makes a hypothesis.Contracting with the parents is an important part of the initial assessment. The parents must understand the necessity for confidentiality and need to be supportive of the therapy. The counsellor is empathic to the parents and gives them the opportunity to voice their concerns and anxiety, however the counsellor makes sure she is the exclusive counsellor to the child and does not fall into the role of counsellor to the parent. Assessment can be conducted in a formalised form, or in a play based experiential and creative way. Oaklander (2007) argues that she discovers necessary things, as the play therapy enfolds. A formalised way of assessment is through the Strengths and Difficulties Questionnaire (SDQ), a brief behavioural screening questionnaire for 4 -17-year olds (“SDQ”, 2018). There are adaptations for parents, teachers, clinicians and researchers. It has three components: 25 psychological attributes, an impact supplement and a follow-up questionnaire. The attributes are divided into five scales: emotional symptoms, conduct problems, hyperactivity, peer relationship problems and prosocial behaviour. Research suggests SDQ is an easy-to-use, free, effective measure for disorders such as ADHD (Perez Algorta, Lamont Dodd, Stringaris & Youngstrom, 2016).Another formalised test is CORE, often used for teenagers as YP-CORE. CORE provides an assessment form as well as an end of therapy form and is useful for tracking the client in process. O’Reilly, Peiper, O’Keeffe, Illback and Clayton (2016) have found that CORE measurements are useful in community mental health service Jigsaw in Ireland.5    Sequentially Planned Integrative Counselling for Children (SPICC)Geldard and Geldard (2008) describe change in the therapeutic process as a ‘spiral of change’. The therapeutic change consists of phases and as growth takes place, the child moves to the next phase, which brings up new material and therefore revisits the previous phase to grow more in that area. The phases are not exact, and revisiting occurs in a different way for different clients. Some children are not ready for all phases. The phases are sequential and for each phase, a different approach is used. Each different approach has its distinct value and fosters a different aspect of the child’s being.The first phase is when the child joins with the counsellor and begins to tell her story. The approach is non-directive client-centred therapy.In phase two, the child continues to tell her story while her awareness increases. The child gets in touch with her emotions and deals with deflection and resistance. The approach is Gestalt therapy. Some gentle direction takes place, e.g. to make a link between the feelings and situation of a piece of art and the child’s life.In phase three the child develops a different perspective on themselves; narrative therapy is the approach and the child’s preferred story is reconstructed and thickened. In the fourth phase the child deals with self-destructive beliefs, unhelpful thoughts and choices. Cognitive behaviour therapy (CBT) is chosen and is directive.In the fifth and last phase of the therapy, the child tries out and evaluates new behaviours. The approach here is the behavioural part of CBT; it is directive and pro-actively promotes change.A child can only do therapy at the developmental level where she is, and therefore not each child will go through each phase. When a child is at a low level of Kohlberg’s moral reasoning and at Piaget’s pre-operational stage, it will not be possible for the child to engage in CBT. Children who present for therapy are often younger in their development than in their years, and the counsellor must take care not to lead the child into a form of therapy she is not able for, as this could reinforce negative beliefs the child may have of herself. 6    ConclusionFor a child to benefit optimally in therapy, the counsellor must strive for excellence. Ethics and theoretical knowledge must be used when choices are made, during assessment and at any phase in the therapy process. The needs of the child come first, and the therapeutic relationship is crucial. The SPICC model utilises the strengths of various approaches. To help a child ease through some difficult passage in her life, is a privilege and gives great joy.