A young figure enters the therapy room. The figure doesn’t have a distinct identity but instead symbolises the infinite personalities, issues and presentations that we see and work with on a day-to-day basis.

This young person could be:

  • The teenage boy who feels stuck in the care system and who has given up on engaging, after previously speaking to several different professionals but never actually feeling heard.
  • The young girl who has moderate learning difficulties and will almost certainly struggle to fit into a traditional talking-therapy approach.
  • Or even the small child who has recently been diagnosed with ADHD and cannot sit still or talk for long periods of time.

The list could go on.

Most of us have been faced with a young person who has presented with therapeutic needs that do not conventionally fit our practice. And the likelihood is that they will either withdraw early from the process or never take full advantage of our help and support. The paradox is that, most of the time, they are exactly the type of young person who could most benefit from therapy.

But what if they are given a voice within the process, beyond the general one we all try to offer? What if we dare to open up dialogues around how they best communicate, and explore what would be helpful or unhelpful for them in the process? This would mean frequently questioning and acknowledging their bespoke therapeutic needs, and working together with them to create something a little bit more personalised than usual, adjusting our practice sufficiently to adapt the framework around them.

These young people with special educational needs or disabilities (SEND) are often those with whom the therapeutic process of shared decision making (meta-therapeutic communication) is going to be especially important. This article is an attempt to explore the idea.

The silent treatment

Today’s society tends to promote a culture built on freedom of expression, personalisation and choice, in which most of us feel empowered – at least to some degree – in our everyday lives. But young people with SEND don’t always get these basic individual rights. And adults don’t always fully listen to and respect what our young people want and need from us, both in the therapy room and beyond.

There does appear to have been some shift in cultural beliefs towards the general young person population: it could be argued they are now more respected and valued in society than ever before.1 But this doesn’t appear to be the opinion of many mental health associations. Organisations such as Young Minds2 suggest that many SEND young people including young carers, victims of abuse and children in the care system are still struggling to get their behavioural, emotional and mental health needs acknowledged, voiced and fully met. This devaluing and lack of accurate intervention is often added to by our judgmental society, which often appears to highlight the challenging behaviours of the SEND young person, seeing them through a criminal, pathological or medical lens. What is often missing, however, is their current need for effective therapeutic intervention at the right time. All of this undoubtedly influences their emotional, social and educational wellbeing, leading to poorer mental health and happiness among the SEND population. The research literature on this is irregular, with an astonishing void in the SEND area. Some papers even suggest that SEND young people are often missing, under- or misrepresented in both counselling and educational research.3,4 Does this lack of research contribute to and compound a sense of disempowerment within the SEND population?

It seems perfectly reasonable to suggest that the way that society views young people with SEND will affect both the counselling process and the way that we interact within the therapy room. In some of my previous research, I obtained a counselling practitioner viewpoint on this concept. The therapists identified children in the SEND category as being particularly vulnerable and susceptible to feeling powerless and being misunderstood by adults and professionals. One practitioner compellingly stated: ‘We must acknowledge that our most vulnerable young people often feel silenced or disempowered by society.’5

Putting the ‘I’ into counselling

In my counselling practice, I quickly learnt that working rigidly within one approach often felt uncomfortable for a young person with SEND. I needed a framework that allowed me to both stay loyal to my core training and also realise the potential of previous trainings, which included my psychology degree and some expressive arts courses. I appreciated, through experience, that each of these trainings held various therapeutic keys within the counselling process, all with different healing potential for the young clients receiving therapy. I had come to also recognise two very important things: firstly, that a single therapeutic practice could not help every SEND young person who walked through my counselling door, and secondly, when I actively involved the young people in conversations around therapy and what could be helpful to them, the process was somehow enhanced.6

As I began reading more widely, I came across the pluralistic counselling framework. This integrative way of working allows a therapist working with a young person to remain open to the notion that young people can become distressed due to a number of different factors.7 Acknowledging that, there must therefore, equally, be a number of different ways in which we can therapeutically reduce the distress and help them change and grow. It means starting with the notion that young people want and may profit from different things in counselling. This, in turn, can enable us to promote a more individual therapeutic experience, where collaborative conversations with the young person can instigate a therapy that is
co-created.7

After further training and hours of clinical supervision, I began adopting this approach with my young clients who have complex and special educational needs. It transformed my practice in many ways, seeming to celebrate their diversity, while acknowledging that there are many different ways to learn, grow and change. It also allowed me to prioritise their unique and differing therapeutic and educational needs, creating a more personalised therapeutic package.8

A shared decision-making approach

Employing a shared decision-making process throughout my work with SEND young people is integral to working within a pluralistic counselling framework. It has helped to increase engagement in both the process and the relationship. Shared decision making involves talking to young people about therapy and together creating a process that is individual. This does not mean pandering to whatever the young person wants, but instead calls for the opening up of a dialogue in which, together, we tease out what might be helpful or unhelpful to their process.9 It can be seen as:

  • The process of speaking to young people about what they want and favour in therapy.
  • The process of choice and preference within therapeutic practice, but also guiding and challenging them when appropriate.
  • Giving them a say in what the counselling might look like, but still using our own therapeutic knowledge to tailor and inform the process.
  • A co-constructed process that can better assist the young person in identifying what might be helpful, and working out together how they want to get there.
    Adapted from Dryden & Cooper, 20168

Although research into this process is still in its infancy, this practice has been shown to improve counselling outcomes with young people, enabling a better relationship to form, and encouraging personal development in both empowerment and self- awareness.10,11 It has a therapeutic purpose in helping to directly develop skills in assertiveness, reflective capacity and communication.12

These practice benefits of using shared decision making within a SEND area help to empower the young person by:

  • Helping us to carefully listen to a young person’s wants and needs within the therapy process, which helps to dispel some of their potential feelings of disempowerment.
  • Helping to identify both therapeutic and educational needs through feedback, prioritising the best form of communication for that young person.
  • Helping us to be open about what we can offer, encouraging conversations around different therapeutic options if the young person should need something diverse.
  • Helping us to promote choice and control in at least one part of their lives, when, quite often, they are directed and told what is best for them.

 

Meeting the anger with a game

During the assessment session, it was clear that Finley had a lot to say, but found talking about his problems very difficult. He could not look at me directly and was stuck, not knowing whether he wanted to talk with me: yet another adult who might let him down. It was also clear, through his crossed arms and aggressive demeanour, that he felt hurt by professionals and family members. They were not fully listening to how he felt, what he had actually experienced, or, significantly, what he thought he needed to do to move forward. In those early moments, it was clear why Finley needed additional support with his learning and why he would almost certainly require something different in his counselling with me. He struggled to sit still, and deliberately turned his back on me, holding a thoughtful and defensive silence. I swiftly realised that, for any kind of therapy to be helpful at all, Finley needed to be given choice throughout the whole process, the kind of control and power that he rarely felt in other aspects in his life.

Following an uncomfortable silence, I offered an ice breaker in the form of a game. He warmed slightly at this offer and asked me if we could play a game of Connect Four. While he was setting up the counters, I began a conversation about the therapeutic process, asking him about his previous counselling experiences. He seemed OK with this and told me that most of them had been pretty negative, and he’d often felt he was forced into the room. I reassured him that working with me would be different and that I wanted to work together with him. I also opened up dialogue around the fact that he would have a joint say in what we did, how we did it and choosing a pace that was best for him.

Developing a picture

As we restarted the fourth game I also wanted to gauge some positives from his previous interventions, trying to tease out what might have worked for him in the past. When I asked a solution-focused question that explored his last episode of therapy, he opened up about what he enjoyed. I made a mental note and reflected on whether I could adopt some of these helpful ingredients in my approach. He informed me that he liked drawing while he was talking and responded particularly well to a playful and honest approach. He looked up at this point, as if uncovering a significant piece of information about himself, and told me that doing something really gave him the courage to talk about his ‘bad experiences’. Again, this was another golden nugget for trying to create a personal counselling experience, as I would ensure that there was always something there to play with while he was disclosing distressful and destructive feelings. Finley was now in full flow as he beat me yet again, winning five games in a row. As we played, he continued to talk about his past experiences of counselling. He stated that it was too long and that he would just shut down after about half an hour. This, again, was a vital piece of therapeutic information, and together, to meet this need, we negotiated our sessions to be no longer than half an hour in length, with the stipulation that he could carry on if he wanted to. I was gaining a very good picture at this point around what type of counselling might be helpful for Finley: he needed something informative yet interesting, short but effective, and playful yet carefully boundaried.

Finley’s preference

The second session felt a little more relaxed as we further agreed a mutual counselling contract, which Finley wanted to officially sign and stamp. As we began, he grabbed some play dough from the table and shaped and moulded it continuously. Sensing that he was settled, I decided to introduce some psychological tools to gain some understanding into what Finley might want from his counselling. Together we used a modified version of the Cooper-Norcross Inventory of Preferences13 that I had adjusted especially for working with young people with SEND. This again opened up an interesting conversation about his therapy, where he highlighted a need to focus on specific goals. He also wanted me to encourage him to focus on his strong/destructive feelings, and shared his desire for me to be challenging but compassionate in my approach. This unlocked further dialogue around previous work with his CAMHS worker, who was very non-directive. At this moment, Finley shared his shame at dropping out of this therapy. I sensed that total control was too much for Finley, who instead needed a careful blend of empowerment and guidance from me. Our connection became stronger as he recognised that I was fully listening to what he needed/preferred and was trying my best to ensure that I provided that environment and intervention.

‘My own therapy’

As our sessions progressed, the shared decision- making process continued. This gave me rafts of continuous therapeutic information that helped inform Finley’s goals, methods and tasks. When opening up a dialogue of options, and sharing other therapeutic activities that could be of use, Finley expressed his joy of using and creating an emotions journal that could be further reflected on in our sessions. He loved this idea, but shared a preference for keeping the log on his smartphone, which felt more natural and where there was (in his words) ‘more chance of him remembering to do it’. This collaborative process was important. It involved us discussing and shaping therapeutic ideas, and was critical when engaging and making the therapy accessible and personable for him, or ‘my own therapy’ as he later called it.

A shared goodbye

We continued to review, evaluate and tinker with the counselling process up until Finley had completed his therapy at around session 14. During our last meeting and final review of our process, Finley discussed his therapeutic achievements and also identified areas of future development for him. After playing one last game of Connect Four, he turned to me, pulled out his phone from his pocket and began reading his very last line of the journal. In an emotional but assertive voice, he declared: ‘Together we were able to beat my monsters, together we were able to help me speak, together we have played through my pain… thank you.’

*Finley is created and completely composed out of the hundreds of young people that I’ve worked with. It is not actual client work, and no source material from any clients is recognisable.

Gary Tebble is a pluralistic psychotherapist who specialises in children, young people and families, both privately and in education, where he works predominately with children and young people who have special educational needs or complex issues. He is also a third-year counselling and psychotherapy doctorate student at the University of Chester, where he is completing research into the use of pluralistic counselling with SEND young people.

References

1 Department for Education and Skills (DfES) Every child matters: change for children (Green Paper). London: The Stationery Office; 2003. 2 Young Minds. Timpson new minister of state for vulnerable children and families. [Online.] https://youngminds.org.uk/blogs/ timpson-new-minister-of-state-for- vulnerable-children-families/ (accessed 7 July 2017).
3 Hill A, Cooper M, Pybis J et al. Evaluation of the Welsh school- based counselling strategy: final report. Cardiff: Welsh Government Social Research; 2011.
4 Department of Education. Counselling in schools: a blueprint for the future. London: Department of Education; 2016.
5 Tebble G. Is talking enough? School-based counselling in Wales. In: Gubi P, Swinton V (eds). Researching lesser explored issues in counselling and psychotherapy. London: Karnac; 2016 (pp187–224).
6 Abrines-Jaume N, Midgley N, Hopkins K et al. A qualitative analysis of implementing shared decision making in child and adolescent mental health services in the United Kingdom: stages and facilitators. Clinical Child Psychology and Psychiatry 2014. Advance online publication. doi:10.1177/1359104514547596.
7 Cooper M, Mcleod J. A pluralistic framework for counselling and psychotherapy: implications for research. Counselling and Psychotherapy Research 2007; 7: 135–143.
8 Cooper M, Dryden W. The handbook of pluralistic counselling and psychotherapy. London: Sage Publications; 2016.
9 Borrell-Carrio F, Suchman AL, Epstein RM. The bio-psycho-social model 25 years later: principles, practice and scientific inquiry. Annals of Family Medicine 2004; 2: 576–582.
10 Wolpert M. Closing the gap through changing relationships: shared decision making in CAMHS. London: The Health Foundation; 2013. [Online.] www.ucl.ac.uk/ebpu/ docs/publication_files/Closing_the_ gap (accessed 30 June 2017).
11 Da Silva D. Evidence: helping people share decision making. A review of evidence considering whether shared decision making is worthwhile. London: The Health Foundation; 2012.
12 Cooper M, Dryden W, Martin K, Papayianni F. Metatherapeutic communication and shared decision making. In: Cooper M, Dryden W. The handbook of pluralistic counselling and psychotherapy. London: Sage Publications; 2016 (pp42–54).
13 Cooper M, Norcross JC. A brief, multidimensional measure of clients’ therapy preferences: the Cooper- Norcross Inventory of Preferences (C-NIP). International Journal of Clinical and Health Psychology 2016; 16(1), 87–98.

Disclaimer and copyright