There is a remarkable lack of high quality research to support an evidence base for counselling and psychotherapy for children. And the words ‘psychotherapy’ and ‘counselling’ are so non-specific that they should always be clarified in more detail. Nevertheless, these approaches are used frequently in child mental health. While most psychotherapeutic approaches are based on work with adults it is important to note that there are marked differences between children and adults. In spite of these obvious differences, psychotherapy for children is usually based on techniques used for adults. However, psychotherapy that may work perfectly well for adults has to be modified to accord with the developmental level of each child.

We each have a mental image of ‘a child’. Often this is a stereotypical child aged about 5 to 10 years old. But the word ‘childhood’ covers the whole period from birth to adulthood, and of course every adult is also somebody’s child. In this chapter the term ‘child’ will be used to refer to anyone who is not an adult, but who has matured sufficiently to develop a clear concept of themselves as individuals and of the nature of the real world around them. The ability to distinguish fact from fantasy is an important prerequisite for psychotherapy. This develops as a gradual process with an important stage at around 2.5 years of age when children normally start to refer to themselves as ‘I’ for the first time. Another stage occurs around 7 to 8 years of age when children develop a clear understanding of time and of the real world. If the therapist ignores these developmental issues it is likely that treatment will be harmful rather than helpful.

Psychotherapy is a very general term that implies treatment of mental dysfunction by psychological rather than physical methods. The aim is to improve function by changing cognition and emotions through the therapeutic relationship, by means of language, play, art, or drama. Dynamic child psychotherapy can be defined as a highly specialized technique where the primary aim is to explore a child’s conscious and unconscious thoughts, feelings, and conflicts in such a way that inner resources become strengthened and enabled. It is child-led so that the child is able to follow and explore his or her own agenda, thus helping the child to make sense of the world and to find his or her own solutions to problems and dilemmas. Therapy is mediated by language, which can either be verbal or non-verbal and may use play or creative activities such as drawing, painting, and modelling. Counselling children is very similar, but the therapist usually takes a more passive role than in psychotherapy and would not be so concerned with the interpretation of
unconscious processes. Cognitive behaviour therapy on the other hand is a highly structured approach focused on challenging false cognitions in order to change behaviour and emotions. It is an approach that can be rather easily adapted to children and made sufficiently enjoyable to engage their interest and cooperation.

A number of interesting paradoxes and dilemmas occur when treating children with psychotherapy (Table 9.5.1.1). For example, who should give consent for treatment. Should it be the child, a parent, both parents, or all three? Clearly, this depends on the age and understanding of the child, and each case should be approached in a way that puts the child’s needs first. It is generally best to obtain consent from the child and both parents. Any other arrangement is likely to lead to problems at some stage. Psychotherapy and counselling are traditionally non-directive and patient-led, but children, unlike most adults, need to be given some direction otherwise they become easily lost and confused. They cannot be expected to find their own solutions without guidance and support. Most psychotherapeutic approaches for adults are based on coming to terms with and finding explanations for problems that are rooted in the past. However, children are still busy making their past, and their main focus of concern and interest is the present and the immediate future. A further dilemma in child psychotherapy concerns the management of the transference relationship between therapist and patient, which is a reflection of the parent–child relationship. A high degree of trust has to be established to use transference effectively. At the same time, it could be argued that it is not really appropriate for young children to develop high levels of trust and dependence on a therapist whom they only meet briefly in very artificial circumstances. Thus any interpretation of the transference relationship in child psychotherapy must be done carefully and with a good understanding of the subtle complexities of a child’s dependency on the parent.

Adult psychotherapy is usually based on a single theoretical model that explains mental mechanisms. Children, however, benefit from the freedom to experiment with a number of different models of their inner world and to learn how to use these ideas in a flexible and constructive way. The use of a single-theory therapy in child psychotherapy is best avoided.

There are undoubtedly differences between child psychotherapy and counselling, but they are difficult to define precisely. This may be because there is a continuum of therapeutic interventions, from advice and guidance at one end of a therapeutic spectrum through more specific counselling and psychotherapeutic techniques to intensive child psychoanalysis at the other end. Counselling children requires a high level of skill, but less theory and technique than in psychotherapy, and it is focused primarily on normal reactions to abnormal events.

Psychotherapy is directed more at psychopathology than normal reactions to stress. It is therefore essential to know about the normal range of children’s responses to life events. For example, a 5-year-old child whose mother has just died will grieve differently from a 10-year-old child, because at 5 years of age most children have not yet developed a clear concept of death. Grief in a 5-year-old is most strongly influenced by the way the adults around the child react to the death, whereas a grieving 10-year-old child, although responsive to guidance from the adults around, will also have his or her own unique way of coping with grief. As a general rule, the younger the child the more important it is to consider the attitude and mental state of the parents.

Dynamic psychotherapy based on the theories of Sigmund Freud and his daughter Anna Freud,⁽¹⁾ Melanie Klein,⁽²⁾ and others has been the mainstay of individual child therapy. More recently, Virginia Axline⁽³⁾ adapted the ideas that Carl Rogers⁽⁴⁾ applied to counselling (trust, genuineness and understanding) and developed ‘play therapy’ as a specific technique for children. Subsequently, brief psychotherapy and interpersonal therapy have grown out of the need to update psychodynamic methods. Various forms of cognitive therapy are now increasingly used for children, although they were originally developed for the treatment of adults by Beck.⁽⁵⁾ These therapies focus on a problem-solving approach to resolve current issues, rather than on resolving unconscious conflicts based in the past.

Counselling and psychotherapy have been used with increasing frequency to help children cope with traumatic events such as death, divorce, abuse, illness, and so on. It is arguable whether this trend is at all helpful. Fortunately, the human psyche is remarkably resilient and there are powerful healing processes that take time, which in most cases achieve a satisfactory result. There are similarities between the way the body and mind respond to trauma and a strong correspondence between the natural healing processes that accompany both physical and emotional trauma. The initial healing process starts with a brief period where no pain or distress is felt whatever the cause of the trauma, and this is often accompanied by disbelief that such a thing could have happened. This first phase of shock and ‘denial’ is then replaced by the full impact of what has happened and is accompanied by high levels of physical or emotional pain. During the second phase the pain may be so severe that it interferes with everyday life, but this stage is usually over within 2 weeks. In the third stage, the healing process continues for a period of up to 6 weeks when the emotional or physical wound is normally healed sufficiently for the traumatized person to be able to return to everyday life, albeit with continuing pain and discomfort at times. The final phase of the healing process then continues over the next 6 to 12 months, leaving a scar that will always remain.

Routine counselling following traumatic events carries the risk of interfering with this normal healing process. Psychotherapy could also be misused to check that all is well, rather like opening up a wound unnecessarily, which will only serve to delay the healing process and might even introduce a secondary ‘infection’. The parallel between physical and emotional healing provides some guidelines as to when and how counselling and psychotherapy should be used, as well as the dangers that can occur when they are misused.