Zara is a recently qualified counsellor working as an intern in a multidisciplinary IAPT team to gain experience towards accreditation. She has been referred to work with Justyna, a 19-year-old single mother presenting with postnatal depression.
Justyna lives in a bedsit with her three-month-old baby and struggles to manage financially, as her only sources of income are Statutory Maternity Pay and Child Benefit. She receives no support from the baby’s father, or from her family, who disapprove of her being an unmarried mother, and she has few friends, having become pregnant soon after moving to England from Poland.
In her first session with Zara, Justyna tearfully describes her frustration and sense of isolation, alone with her baby 24 hours a day. She is exhausted, as she has not had a full night’s sleep in three months. She expresses feelings of guilt and shame when she tells Zara that, sometimes, when she can’t get her baby to settle, she has thoughts of wanting to shake her, although she hasn’t done so.
Reflecting on the first session, Zara is unsure how she should hold her concerns for Justyna and the welfare of her baby, and what, if any, safeguarding duty she might have to report the case to statutory services.
What would you do in Zara’s situation?
Supporting mother and baby
Surabhi Chaturvedi (BACP-accredited integrative psychotherapist)
It is easy for practitioners to fall into the trap of thinking about safeguarding as a duty of care just to the child. But, in this scenario, there is perhaps a duty to safeguard the ‘mother-and-baby unit’ as a whole. Also, ‘reporting’ someone to the authorities sounds quite punitive, but there are times when safeguarding is more about ‘referring’ someone for support.
Although there is no current indication that the baby has been harmed, there is a potential risk, due to Justyna’s extreme distress. Zara should discuss her concerns with her line manager or the agency’s designated safeguarding lead. She should tell Justyna what she intends to do, and give her the opportunity to say how she feels about this, even if it doesn’t change her decision.
Thinking of safeguarding as a duty to the mother-and-child dyad may help Zara frame a referral to statutory services as a way for Justyna to get support, rather than as a punitive measure (which is a common perception of social services).
As many of Justyna’s support needs relate to her social isolation, housing and income, a purely psychotherapeutic intervention is unlikely to meet them all.
A referral to statutory services may result in Justyna receiving parenting support or financial assistance, which would help her cope better. It would also free up Zara to focus on her primary role of offering therapy to help Justyna with her depression.
Zara should also use supervision to give her the psychological and emotional robustness she needs in this role so she can help Justyna process her feelings of isolation, guilt and shame.
Seek advice and monitor carefully
Judy Stafford MBACP (person-centred therapist in the voluntary sector)
Zara is in an IAPT multidisciplinary team and therefore has access to the advice of more experienced peers. She also needs to discuss her concerns with her supervisor.
Regarding safeguarding and reporting the case to social workers, it is important that Zara doesn’t panic and pick up transference from her client, and that she takes advice and monitors Justyna carefully. If Zara feels she is not working within her competence, she should discuss with her supervisor whether she should refer Justyna to a more experienced therapist.
Justyna has multiple needs that are beyond Zara’s remit to address. Zara’s role, if she continues as Justyna’s counsellor, would be to form a caring relationship that avoids dependency. Once she has gained Justyna’s trust, Zara could help her to explore her needs/concerns. Justyna should be encouraged to visit her GP so she can be assigned a health visitor to ensure her baby has regular health and progress check-ups, and the health visitor would also be able to give her information on mother-and-baby and other peer- and social-support groups and activities, and advice on how to cope with the child.
The father is financially responsible for the baby, and the Child Support Agency, or the new Child Maintenance Service that is replacing it, can seek to enforce his contributions to his child’s upkeep. Although Justyna’s family reacted badly to her pregnancy, they might support her if they know she is struggling. She may have taken their initial rebuff as final and withdrawn from further contact.
Justyna needs encouragement to establish a routine with her child and venture outside. She has come for counselling, presumably leaving the baby with someone; this shows her determination to do something about her situation, and Zara can help her build on this.
Manage risk appropriately
Nicky Marshall (integrative transpersonal psychotherapist, supervisor and trainer)
This dilemma concerns safeguarding, and the possible conflict between Zara’s duty of care towards a vulnerable child and the confidentiality she owes to Justyna as her client. As she is working for an agency, Zara will be required by her employer to follow its policies, which should specify the actions to be taken in these circumstances.
It is to be hoped that Justyna is aware of the limits to confidentiality within the therapeutic relationship, and that the contract Zara has agreed with her sets this out clearly. If Justyna is already aware that her counsellor cannot keep quiet about risk to a child, it opens the way for a dialogue about what she hopes may happen now she has disclosed her stress and distress; at least some part of her was maybe hoping that this would be a way of getting support.
Zara would do well to reflect on her own level of concern and consider it in terms of this being Justyna’s way of communicating her own stress and anxiety. She should discuss Justyna’s needs in supervision as soon as possible, and possibly with other colleagues in the multidisciplinary team (assuming that the confidentiality agreement is between the client and the agency, not simply with Zara), to ensure that all potential risks are assessed, and that Justyna has access to all available, appropriate resources.
Need for longer-term support
Claire Thomas (team manager and primary care counsellor)
This vignette highlights the tension between the therapeutic relationship and the necessary trust I, as a person-centred counsellor, place in a client’s process, and the statutory need to safeguard Justyna’s baby, which the client may experience as directive, and therefore counter-therapeutic.
As an intern in an IAPT team, Zara is required to follow the organisation’s safeguarding policy, and she should have contracted with Justyna before beginning the work and informed her about the limits to confidentiality. The need to make a referral to children’s services should not, therefore, come as a surprise, but may still mean that the therapeutic relationship is ruptured, perhaps temporarily, or perhaps irreparably.
Alternatively, Justyna may be relieved that support is available, and, if the referral is done sensitively, it may lessen the negative impact on the therapeutic alliance. Zara could, in the next counselling session, support Justyna to contact the children’s services herself.
Zara would also be able to call on her team’s broad expertise and discuss her work with Justyna in supervision, and also, perhaps, in a clinical discussion meeting with colleagues, where they could share the wealth of their experience.
A key issue here is Justyna’s isolation. Zara can draw on the team’s collective knowledge of local services to signpost Justyna to resources other than counselling. Accessing more practical support would also be important, as Justyna is likely only to be offered six to 12 sessions in an IAPT service, and signposting could provide her and her baby with longer-term solutions.
Opinions expressed in these responses are those of the writers alone and not necessarily those of the column editor, Therapy Today or BACP.