Project Description
Integrative systemic therapeutic outreach approach with schools and families.
As a systemic family psychotherapist with significant experience working within social care and CAMHS (Child Adolescent Mental Health Services) with young people and their families I have become increasingly aware of the link between emotional difficulties and stability for some vulnerable young people within a school environment. Within my former therapeutic partnership working with schools, young people and their families the school context for some young people can be experienced as an additional stress to their current situation. This can accumulatively result in frustration for the school, young person and the family.
Within the wider context there has been an increase in young people’s mental health needs generally within the population where young people have been identified as subjected to increased competing pressures, as a result of social isolation, struggling academically, questions about identity, and a sense of hopelessness which has been enhanced by the current pandemic. Prior to the Pandemic it was recognised by Public Health England “Universal Approaches to improving children and young people’s mental health and wellbeing 2018” the need for a systemic review of childhood mental health was needed. Within this context an emphasis on a Public Health Model where a prevention strategy and integration of services has been recognised as key.
It is within this context that a joined therapeutic approach between the family and the school gives scope for the “change process” to take place where a young vulnerable person can emotionally feel a sense of containment and being emotionally held by all parts of the system.
Young people irrespective of their age can find the uncertainty about their future and the sense of hopelessness overwhelming. During this difficult time parents and carers (who themselves maybe struggling with their own competing challenges) are not always able to support the young person and be emotionally available in the way that they would like. This can culminate in both parents and the young person feeling vulnerable resulting often in closed down or volatile communication. Often help is sought when the situation has reached a crisis point and there are concerns about a young person’s emotional difficulties potentially presenting in self harming, difficulties in managing anxiety, verbal and physical aggression which can manifest in conduct disorder presentation. It is often within schools that such behaviours are first identified. The following therapeutic joined outreach model offers a systemic integrated approach in working with the young person’s difficulties.
The Structure of intervention
This programme is available in the following way:
*A direct expression of interest can be made by a parent or carer directly to myself individually who wants therapeutic support in working with the young person, school and themselves.
OR
*The school can make a direct referral to purchase a therapeutic service for a specific young person with significant emotional needs who would benefit from a joined therapeutic approach with the school and carer/parent.
- For young people who are struggling with layers of emotional challenges due to themes around separation and loss, and relational conflict as a potential result of significant issues such as bereavement, intrafamilial conflict, relational trauma which has impacted on a young person’s education.
- For a young person with an undiagnosed learning difficulty or social communication diagnosis such as ADHD compounding a young person’s emotional well being would be given consideration for this programme.
- For young people who are at risk of school exclusion, on the cusp of care or custody and at risk of gang affiliated activity or of child sexual exploitation.
- A key criteria for this approach are that the joined therapeutic sessions are attended by a designated educational member of staff carer/parent and the young person. (Prior to joined work taking place individual sessions with everyone involved will take place to prepare for this phase of intervention to build up the relational alliance and to create a context of trust to be established.)
Family therapy is an evidence-based intervention supported by the NICE guidelines for a number of mental health presentations particularly in relation to conduct disorder and challenges with emotional regulation. Equally it has been recognised that a relational approach which enlists all of the system particularly the family is key in the “change process”. The relational approach embodies not only a contextual safeguarding framework it proactively works within the child’s immediate network within a strength-based framework to engage in the process of holistic long-term enduring change.
Within this context I work systemically using a relational attachment approach. This phased approach aims to work both individually and jointly with all respective parts of the system. From the beginning of the therapeutic work the young person is engaged with intensively building up the therapeutic alliance to identify where the “attachment rupture” for the young person is embedded. The parental and educational system will be worked with concurrently as part of the therapeutic engagement process with the objective of reframing problem saturated narratives to a joined relational task.
Through the therapeutic process of “intersubjectivity” in attuning to the young person’s emotional needs, the subsequent joining with the system takes place to enable the parents/carer and the school to “hear” the young person’s emotional needs and concerns. It is within the mutual experience of the system mentalising the young person’s emotional needs that the potential for therapeutic change can take place.
Systemic Assessment:
Prior to therapy taking place a systemic assessment would take place. A contextual risk assessment considers the multi systemic issues surrounding the young person, his/her family circumstances the role of the community and his /her position within the school. The family and key designated educator would be part of this assessment. The assessment will consider the following:
- Are there enough protective factors within the school and family to support and stabilise the young person through the joined systemic therapeutic approach?
- Is the immediate clinical risk too high? Consideration of a supported referral to another service will be addressed if needed to stabilise immediate mental health crisis prior to engagement in therapeutic work. It should be noted that collaborative work with other clinicians offering therapeutic interventions and assessments will take place prior to a reassessment for long term therapeutic relational work takes place.
Pending the outcome of the assessment the following can be offered:
*Referral and signposting to appropriate services for high risk mental health presentation with view to reassessment in the future for long term relational work with the respective appropriate agencies.
*Intensive Family Therapy intervention offered for six months subject to a relational review at three months.
Prior to the relational review at three months the therapeutic intervention would focus on engagement and relationship building and trust. Individual relational sessions are delivered where concurrently individual sessions would take place with the young person, carers and designated educator.
Post assessment where long-term relational therapy has been agreed by all parties concerned, an initial joined contracting session takes place. The aim is to agree and formalise the identified work to be done. The therapeutic task is framed relationally and agreed by the school, family and the young person.
Within the subsequent two months individual sessions with the young person take place therapeutically to build up a therapeutic alliance and trust using the process of strength-based framework. Within the engagement phase the process of intersubjectivity is used to emotionally attune to the young person’s experience of their attachment rupture and their respective relational difficulties. Concurrently individual sessions take place with the respective carers responding to their relational difficulties and exploring possible links to their own historical respective attachment issues which might be having an impact on their parenting relationship.
In consolidating the relational engagement stage individual sessions take place with the assigned educator (attachment agency representative) and the therapist to reflect on the key relational themes. Consideration is subsequently given to the potential therapeutic joining role that the school can play as a protective factor towards the overall therapeutic repair process in preparation for stage 4 Joined Relational Work.
Within the remaining three months ongoing joined therapeutic joined work takes part with all of the system to address the relational task with a view to stabilising the young person. It should be noted that intermittent outreach motivational top up sessions are offered to the young person concurrent to this process by myself to monitor motivation, triggers motivation and emotional vulnerability.
The aim of the joined relational work is to mirror the process of emotional attunement and intersubjectivity therapeutically by fostering the concepts of empathy and curiosity and playfulness. As the educator and respective carers replicate this therapeutic holding framework, consideration is given to the young person’s underlying triggers and emotions which impact of their difficult behaviours. Through the therapeutic process where the young person experiences feeling mentalised and held emotionally in a congruent and consistent manner, then the change process away from relational rupture to repair can start to take place.
In the seventh month of the programme a “Contract of Change Relational Plan” is drawn up between the young person and the school and family, and potential ongoing community resource such as a mentor will be considered to provide ongoing support for the young person to help consolidate the changes to take place long term. All parties contribute to the plan and the designated role they will provide to support the change process for the respective young person. Consideration at this stage of consolidating the emotional repair work with behaviour strategies will be addressed and shared with the respective carers and the school and young person.
A top up of 3 sessions is provided as necessary in terms of support within a three month follow up basis as required prior to the final evaluation taking place.