In this collaborative article, we explore some of the methodologies used by our network members as they strive to provide the best outcomes for children and families.

BFN therapists believe that supporting the child within the context of the family aligns with our holistic approach. Of course, as a community interest company, we do have the luxury of being able to work without the constraints often imposed by statutory or voluntary agencies. And this means we can embody the values and philosophy of best therapeutic practice, such as long-term work, shorter waiting lists, early intervention and flexible responses. Members of BFN are proactive in their mutual support and willingness to learn from each other. But in order to share more widely, we have asked some of our therapists to explain their model for working with parents and children within the family dynamic.

Justine

As a counsellor in a secondary school, it’s not necessary for me to involve parents in the work I do. Young people can self-refer, or members of staff can advise that a young person take up counselling. But it’s their choice. Young people use the service because they feel empowered to do so and choose when to start, stop, take a break or never come back. But on occasion, I have enlisted the support and advice of a parent. I’ve found that this mostly occurs with the younger adolescents I work with.

Some professionals might view engaging parents with their child’s counselling as overstepping the boundaries of ethical school counselling. However, in my experience, understanding family circumstances can greatly support the counselling process. Engaging the family often reaffirms, sheds new light and offers solutions that I may not have previously considered. 

Meeting parents, whether they share the same home or are part of a bigger, more complex family structure, adds a different perspective to the work I do. It’s about the pieces of the puzzle that are not always apparent when working with a young person in isolation. Often, young people are unaware of how experiences within their family have shaped their thoughts and feelings. But many of them may feel shame and do not see the relevance of sharing family information, or how it can support their therapeutic journey. It’s clear that counselling can be more meaningful if we have understanding of our client’s past, including their early childhood experiences and parental attachments, as these have the potential to support or threaten the therapeutic journey we embark on together. If the school counsellor lacks this knowledge when operating within a student self-referral system, it can sometimes feel as if they’re working in the dark.

My clients are often struggling with understanding their abilities and limitations in the new environment of the secondary school. Working with parents and carers, and supporting them to understand those struggles, can be beneficial. Parents can then help their child in their search for belief in themselves and the world around them. And through contact with the counsellor, parents can help their child with strategies to deal with the often difficult and confusing transitions of adolescence.

Of course, as I said, working with parents as a school counsellor is not always appropriate. One of the most important relational changes for adolescence, in terms of social and emotional development, is that of separation and individuation. As they become less dependent on their parents and begin to form separate identities and take on their own lives, conflict between young people and their families may increase. Kirkbride1 states that young people are frequently resentful of parents’ interference in their world, and this often leads to them seeking advice and support from outside the family in order to feel more in control of their decision-making.

Seeking support in school, therefore, is a form of autonomy – which is why the relationship a school counsellor has with the client must be respectful and sensitive to the client’s needs. So while facilitating a dialogue with client and parent feels a natural way of working for me, it’s not always possible or appropriate to do so. Some clients need to feel that there is separation between school and home; so involving parents does not suit all client work.

In any case, in a school environment, the most effective therapeutic work is often achieved by checking in with clients regularly for short periods, keeping them in mind, being visible around school and offering them a safe space to unpick issues. This allows them time to build resilience and confidence.

Lucy

In the particular way in which I practise art therapy, both parent and child are integral to the therapeutic model, input is time limited and has a goal-oriented focus. The model2 stems from Cristina Zago, a senior art therapist, who devised The Brief Art Therapy Clinic, and I have further developed it in a community CAMHS team. It offers eight to 12 sessions with the parent/carer alongside their child. It involves input from the art therapist and one other therapist from the team.

This could be a family therapist, social worker or mental health worker. The method was devised to support families struggling with a specific difficulty of fairly recent onset. It’s not considered appropriate for chronic long-term difficulties.

The aims of the Brief Art Therapy Clinic are

  • To provide the opportunity for a small change 
  • To support a specific transition in a child’s life
  • To address a specific difficulty and/or to offer support around a particular anxiety 
  • To provide the opportunity to assess the child’s view of their situation and their state of mind.

At the start of treatment, there is a joint meeting between the child and their parent, in which each sets a small goal that is felt to be achievable. Eight to 10 sessions follow, with a final review to complete the work. Sessions are on a weekly basis if possible. The art therapist offers an individual space for the child, while the other therapist works with the parent at the same time. For the final part of the session, the child and parent are brought together to explore the themes that have emerged. The model is flexible so that we can also work with parent and child together, making artwork.

This model is beneficial in that therapists can share ideas and approaches that are appropriate for the child and parent. There is often resonance between what the child brings to the art therapy and what the parent brings to the discussion. The work combines both psychodynamic and systemic ways of thinking, which benefits the children and their parents. It supports a move away from the idea that ‘therapists are experts’ and fosters a collaborative approach between therapists and parents. There are often poignant moments when parents recognise and comment on themes in their child’s art work – the art therapy provides insight into the young person’s inner world and feelings about their situation, which can then be reflected upon together.

One of the advantages of this model is that parents and children can explore shared memories and also thoughts and feelings about the future. The individual work with the parents offers therapeutic support in addition to psychoeducation about their child’s communication, both verbal and non-verbal. Using this model and goal setting, we are able to focus upon the desired change.

Lorraine

In my role within BFN, I, too, work closely with parents and children to effect change – using CBT. And similar to Lucy’s work, my interventions are short term and solution focused. 

CBT seeks to identify and challenge negative automatic thoughts, explore more realistic interpretations, and bring behaviours under cognitive control. CBT can be used with children, young people and adults.

Parents are often present in a child’s CBT sessions, particularly in the treatment of separation anxiety, generalised anxiety and phobia. Parents are more likely to be present with younger children than with adolescents.

It’s important to hear the parents’ view of the presenting problem. Children are part of a family system in which they learn how potentially anxiety-inducing situations are interpreted and managed. Involving parents can also be informative in understanding how a child’s vulnerability to anxiety may have been encouraged or maintained, albeit unintentionally. And if parents have their own difficulties with anxiety, the work may be more effective if this is addressed before treatment with their child begins. How a parent responds to their child’s anxiety can be enlightening. If they demonstrate anxiety or frustration, this affects the child’s ability to manage their own feelings. The sessions where parents attend alone can be an opportunity to explore behavioural changes they might make to support their child. This work is a collaborative process and the family is crucial in supporting and encouraging the child between sessions and when therapy has ended. In order to develop an intervention plan as part of CBT treatment, it’s important to share an understanding of the problem and agree goals.

I will often teach the parent and child breathing exercises and muscle relaxation techniques to help them manage anxious feelings, and I encourage them to practise these at home. I also help them to identify behaviours and unhelpful thinking patterns that are at the root of their difficulties. For example, if working with issues of anxiety, I will explain the anxiety cycle and its maintenance through avoidance and reassurance seeking – I encourage parents to promote a ‘have a go’ attitude, to discourage avoidance, and to resist the urge to constantly reassure when faced with challenging situations. In parent-only sessions, they can be shown how to ask the right questions of their child in order to identify the unhelpful thoughts that need to be challenged. The aim is for parents to encourage their children to become independent problem solvers, with the child coming up with their own solutions to manage anxious situations and evaluating how useful this is in the short or long term. Together, the family and I create a step-by-step (graded exposure) plan of behavioural challenges, supported by rewards and praise.

Sue

As a longer-term approach to working with families, and as an integrative therapist and parent facilitator, I use my knowledge of attachment to work with parents and children to develop new relational models to support the development of connection and build resilience within the family. So there are often times when I negotiate to work with the parent and child together. I’ve found it particularly beneficial with families who have experienced parental bereavement, separation and divorce. And in the case of developmental trauma, the work of strengthening the attachment relationship is a fundamental step before trauma can be processed.

This work is essentially about encouraging and supporting a different relational model between parent and child in order to provide Winnicott’s ‘holding environment’,3 so that behaviours, thoughts and feelings can be explored in a playful and accepting way, thus enabling ‘good enough’ parenting to strengthen the child’s sense of self.

Initially, I see the parent(s) separately for at least two sessions to help gain an understanding of their attachment style, and assess how the parents manage their own regulation and attune to the needs of their child. It may be appropriate for parents to seek therapy for themselves, and this may be gently suggested. It’s also an opportunity to introduce some psychoeducation regarding normal child development, attachment and mentalisation, and to discuss what the sessions will involve.

A major part of the work is encouraging the parents to shift from seeing the child as ‘the problem’ to understanding the child within the context of his development, his history and his family. When the parent is initially reflecting on their child, there is often an expectation that the behaviours of the child need to be challenged. The biggest hurdle of the work is therefore to curb some of the impulses of the parents. For example, often parents will need to be ‘right’ or insist on their children using materials or toys in the correct way; or they may perhaps struggle to tolerate mess, or can’t bear things to be ‘mislabelled’. In addition, parents coming for help are often unused to talking about their own feelings, or have an expectation that their child will open up about difficult feelings, and are surprised when the child shuts down, changes the subject or becomes hyperaroused. I’ve often found it useful to talk about Siegal’s4 Window of Tolerance to help parents understand why children begin to dysregulate.

As the work progresses, sessions start with feedback and exploration of any challenges from the previous week. We use art, play and sensory-based activities, such as throwing beanbags, mirroring games, drawing around hands, creating family using figures in the sand tray, or playing musical instruments together. Each session ends with the parent reading a story to the child. Part of the work is to model a different way of being with the child. I might encourage the parent to observe my relationship with the child while I model playfulness, curiosity, acceptance and empathy (Dan Hughes’ PACE5). Observation is also helpful, as I will inevitably get it wrong with the child in some way, and I can use this opportunity to model repair in the relationship. Alongside, I encourage the parent to spend 30 minutes a day with their child, letting them lead with their choice of play materials, while holding the boundaries of safety. I encourage them to convey an accepting and non-judgmental way of being with their child.6

In many ways, it’s more challenging to support the parents to improve the relationship with their child than to work with the child in isolation, focusing on building a therapeutic alliance. However, ultimately the work of being alongside a parent and child and facilitating a healthier relationship – where feelings can be discussed, ruptures repaired and children can begin to feel accepted and understood – is hugely rewarding.

In summary

At BFN, we wholly appreciate the rewards and ongoing effects of working in the family dynamic. However, at the heart of all of our work is the knowledge that the child’s wellbeing must take precedence. In the case of individual child referrals, decisions to include parents must be carefully considered along with the child’s right to confidentiality and safety. For example, the therapeutic space may be a child’s only refuge from a chaotic world, and inviting parents into this space without careful preparation and clear boundaries could jeopardise any therapeutic gain.

Being in the family dynamic is not a simple process; the anxieties of both parent(s) and child need to be contained by the therapist, often in challenging circumstances. But working positively with families can effect change that continues long after the therapy has ceased.

Sue Barr is Chair and Karen Storrie is a director of Bucks Family Network. With thanks also to Justine Briggs, Lucy Duckworth and Lorraine Leeper.

References

1 Kirkbride R. Counselling young people: a practitioner manual. London: Sage/BACP; 2017.
2 An informal approach trialled but not documented. Cristina has given the author her permission for it to be written about here.
3 Winnicott DW. The maturational processes and the facilitating environment: studies in the theory of emotional development. London: The Hogarth Press and the Institute of Psycho-Analysis; 1965.
4 Siegel DJ. The developing mind. New York: Guilford Press; 2012.
5 Hughes DA, Baylin J. Brain-based parenting: the neuroscience of caregiving for healthy attachment. New York: WW Norton; 2012.
6 Landreth GL, Bratton SC. Child parent relationship therapy (CPRT). New York: Routledge; 2006.