Therapy with individuals works in many ways and across many models of psychology and, although it can be incredibly successful, there are times when therapy is not productive or ethical.
Firstly it is important to acknowledge that psychotherapy is a journey across time and is not, generally, something that happens quickly. This is because it takes everyone different amounts of time to begin to trust the therapist and, of course, to develop rapport. Without trust and rapport, nothing can be explored satisfactorily since the therapeutic alliance is always the most important part of therapy.
Models of psychology
Through the ages psychology and psychotherapy has brought forth different ways of explaining and naming different ways we think, feel, talk and act and, indeed, different ways of changing these to produce better ways of engaging.
The current model that has caught the eye of professionals is Cognitive Behavioural Therapy, usually termed CBT. CBT is described as a psychotherapeutic approach that addresses dysfunctional emotions, behaviours, and cognitions through a goal-oriented, systematic process. It is currently favoured for two reasons, one is that it is prescriptive and thus easily researched for efficacy therefore it has been proven to have good results. Secondly, it is easy to use as a discrete model and works in the ‘here and now’ to alleviate troublesome symptoms. For this reason it is cited in the NICE guidelines put forward by the government as something to be recommended for many mental health problems like depression, anxiety etc.
At SureCare we use CBT as our core model of development for training and also, where it is the most appropriate, as a way forward with individuals in therapy. However, this is not the only model that is used, since training is offered in systemic ideas [also mentioned in the NICE guidelines], solution focused ways of thinking and behavioural styles, all of which can be helpful.
How individual therapy helps in different ways
Firstly, therapy can be great just to act as a place to witness the pain, sadness and difficult experiences of the client. The therapist can simply be another person who accepts the client, their stories and their difficulties. Many clients are happy that they are believed, taken seriously and that someone else can hear disturbing episodes and stay with them, without judgment or comment. It may be that this is the first time the client has experienced another person taking this position and it can feel very validating.
Secondly individual therapy can be used to consider behavioural interventions. These are generally focused on concrete aspects of life, offering clients ideas about identifying patterns and ameliorating these with new ways of trying to achieve needs in a more efficient manner. Examples of this might be structured plans, negotiated rewards/sanctions etc This is probably the easiest way of helping clients, since it does not require them to actually begin to consider the more complex concepts of psychology depending, as it does, on actions rather than thoughts/feelings.
Thirdly therapy can be useful for clients to increase their understanding of thinking patterns and the way the brain interacts resulting in life choices. This is often termed psycho-educational ways of working. Examples of this might be teaching how the brain parts function, how thoughts/feelings/physiology all interact. This is quite a tough part of therapy to understand since it requires deeper thinking with regard to psychological knowledge.
Therapy is also a time to explore the meaning of life from the clients’ perspective. Without actually identifying and understanding the way the client views their world and the world of those around them, therapy is not effective since the client may feel that the therapist has not joined their narrative. A ‘shared meaning’ in the therapy room is essential so that the therapist can show the client their view is valid, thus validating the sense of self, which is imperative. This does not mean the world view is not to be challenged if it brings about damage for the client, it simply means the view must first be identified and understood prior to working on it. An example of this might be helping the client to identify episodes that they view as having external causation and moving into a more internal/external realization.
Finally and the most complex part of therapy is actually when the therapist begins to psychologically deconstruct and re-synthesise the client’s own past experiences, identifying historical impacts on current choices and helping the client notice what constraints and what opportunities these patterns offer. Examples of this might be helping the client to notice their attachment styles, how these are being used currently and the nuances of subtle needs being suppressed, expressed or ignored, the results of these choices and the feelings this brings about. This is the most complex part of therapy and requires a therapist who is able to contain, explain, explore boldly and be responsible enough to open doors with graciousness and respect BUT with the ability to close those doors so that the client remains safe in the real world.
Therapeutic journey seen as four stages towards change
1. Initially clients become AWARE that they are unhappy with aspects of their life and that they are ready to make changes but, maybe, those changes are not open to them without further help or different resources.
2. Then clients may enter therapy and begin different ACTIONS [verbal, physical, thoughts, feelings] towards trying out different and, hopefully, more helpful ways of engaging with the world.
3. The third and most important part of this route is three, when clients ACKNOWLEDGE the new actions as bringing about better life episodes, exploring how this happened and maybe refining new ways of working in their world.
4. Finally, when the ACTIONS/ACKNOWLEDGEMENTS have been thoroughly tried over time, the client is perhaps ready to reach the fourth part that is termed ACCEPTANCE. At this stage the client has begun to break unhelpful patterns, develop better ways of engaging, and is beginning to use these new skills as default, avoiding old mistakes.
Restrictions to therapeutic success
Although of course all cases are unique and there cannot be any rules applied in a generic manner, there are a few contexts where individual therapy might be considered counter-productive, :
1. If the client is not willing to engage in therapy it is unhelpful to press that person. As already stated, the most important part of therapy is to construct the most positive therapeutic alliance and if the client is not willing, this is impossible.
2. If the client is ‘firefighting’ then therapy is often unhelpful. This put simply means that if the client is too stressed with one or two specific episodes in their current life, it may not be useful to try and explore deeper maybe historical aspects, in an effort to help the client understand patterns. The therapist needs to deal with the current trauma initially and this may well take the discussion into more productive but, perhaps, less therapeutic areas.
3. If the client is too depressed, tearful and sad, then therapy can sometimes be less helpful, since discussion of more painful stories can bring about even more depression. This is often where medication is sometimes considered alongside therapy [see NICE guidelines].
4. If the source of sadness is ultimately ‘normal’ eg if the client has recently been bereaved, then a period of low mood, tearfulness, poor sleep is perfectly understandable for a short time.
5. If the client discloses something that is ultimately illegal or unsafe, then therapy cannot proceed without agreeing a way forward to deal with the information.
6. If the client is proceeded into therapy upon the needs of the system ie the family, the carers, the school. This means that, at times, a system will promote the ‘problems’ as if they were located within one member of the system, which is rarely the case, since life is generally interactive. In this context it might be unethical to begin individual therapy without including the system in the work at some level and at some stage.
7. If the client does not have a safe context or a network that is perceived by them to be safe, then to take them into a therapeutic liaison may be more harmful, since all clients will need a feeling of safety on the outside of the therapy door.
Therapy and young people
If it is deemed appropriate by all the professionals involved, all young people in SureCare are offered direct individual therapy. However many young people who are in the looked after system have undertaken therapy prior to their placement and this is generally something they have found to be difficult and often not successful. Usually the reason for the lack of success lies in the very chaotic nature of their system [home and carers] and lack of structure to their context [school and friends], not in the way they engage [within child perspective].
If the young person has not had a good therapeutic experience it can be extremely hard to encourage them to try this intervention for a second and, in some cases, third time. For this reason, individual therapy is always offered but never relied upon as the sole intervention since we can therapeutically help the young person in many ways.
If young people choose not to access this resource immediately, SureCare still plan a therapeutic programme based on:
Information given by the young person
Information given Family or Carer
All paperwork held in files
Knowledge of SureCare staff
Observation of the young person
Ongoing sharing of information by all who know or work with the young person
This therapeutic programme will become part of the Care Plan and also will be monitored and reviewed via Clinical Supervision and Peer Supervision, both facilitated by SureCare’s consulting psychologist/psychotherapist.
A therapeutic approach is not the same as individual therapy. Whilst individual therapy is extremely helpful and is to be encouraged, it is clear it is not something that can be accessed by all the young people for many different reasons. However, at SureCare ALL young people receive a therapeutic approach, which is in effect indirect individual therapy, since it is based on the same evidence and psychologically managed.