Seventeen year old Amy was what I would call a ‘silent’ client.
Her mother had asked me to see her after a difficult experience attending a mental health service. She had been referred when everyone around her got worried about her increasing self- harm and thought she had actually become a danger to herself.
But there was a lengthy delay in getting her any help at all. The waiting list was over 4 months long, during which time Amy’s anxiety continued to grow. When she was finally seen, the ‘help’ was less than helpful, with fortnightly appointments with a psychiatrist of only 20 minutes. After a few sessions, Amy reported she had stopped self harming and was signed off.
Amy was now, according to mum, very angry about the whole experience which she called a ‘waste of time’, and was angry with the GP too for referring her there in the first place. Mum was still concerned about the self harm and bewildered as her daughter now seemed very depressed, but, as far as the unit was concerned, she was ok.
A mental health crisis
There’s no doubt our mental health services are under increasing pressure. More than a quarter of children referred in England in 2015, including some who had attempted suicide, received no help, a recent report says.
The review by the Children’s Commissioner found that 13% with life-threatening conditions were not allowed specialist support. Commissioner Anne Longfield said she had heard from a ‘constant stream of children, parents and professionals’ about their inability to get help when they really need it.
‘They go to their GP who refers them to specialists, but the specialists then say their conditions are not serious enough’, she said. ‘I don’t yet know quite why they are being turned away, but certainly being turned away or put on a waiting list is clearly playing Russian roulette with their health,’ she added.
The commissioner obtained data from 48 of England’s 60 child and adolescent mental health service trusts, and discovered 28% of child referrals were denied specialist treatment, mostly on the grounds that their illness was not serious enough. This group included children who had attempted serious self-harm and those with psychosis and anorexia nervosa.
It also found that those who secured treatment faced lengthy delays, with an average waiting time of more than 100 days.
My first session with Amy
After all the upset, it appeared to me, on our first session; that Amy was still ‘window shopping’ as far as therapeutic coaching was concerned. She certainly hadn’t bought into the idea that our work together could be helpful to her, and it looked like one word answers might be all I could expect for the moment.
It seemed also that, for Amy, taking control of the session in this way was symbolic of how she had been trying to take control of her life, albeit in ways that had been potentially very harmful for her.
I soon established the self harm had started out as a way of coping with the anxiety caused by the bullying she had experienced at school. But what had began as a way of taking control had now taken control of her, her thoughts, feelings and actions.
Self harm, often in the form of ‘cutting’ is the kind of coping mechanism which gives temporary relief from emotional distress, due to the feel-good endorphins it releases in the body, but this mechanism can get hijacked by the addiction pathway of the brain. The temporary relief which comes with self harm creates an illusion of control, but that control doesn’t last for long.
In our first session together, I taught Amy a relaxed breathing technique I knew would help deal with the anxiety. However, when she returned the following week she had not practised the technique once. Not surprisingly, nothing much had changed and Amy was still low mood, low-energy and low motivation.
Still, this time, at least she was more talkative.
What we focus on is what we see
Sadly, it became apparent Amy was focusing on all the negatives.
‘I hate my life’ she told me. ‘I hate school and everything about school.’
‘What is it you hate about school so much?’ I asked her.
‘I hate getting up early in the morning. I hate having to wear the uniform. I hate the school bus and all the trouble on the bus. I hate the bullies and I hate the arguments. I can’t wait to get away and go to university.’
‘What do you want to study at university?’ I asked, seeing an opportunity to make a possible breakthrough.
‘I don’t know’ she said tiredly, as she revealed that she actually hated the subjects she was studying. Amy’s former lethargy returned and the whole session left me wondering whether I would be able to connect with my young client or, more to the point, whether she would allow herself to connect with me.
The therapeutic alliance
What we call the ‘therapeutic alliance’ is very important in the kind of interactive work I do.
I had to give Amy the hope that our work together was going somewhere and I had the sense this must happen fast. It wouldn’t be long before she decided this whole’ talking therapy thing’ was not right for her. She would either refuse to come to further sessions or sabotage the process by not doing the homework tasks I gave.
When she came to her next session I was ready, and fully prepared to work very hard indeed.
I would need to draw on some major skills and tools from my professional toolbox. This one powerful session would start with trauma resolution and end with pure coaching.
What we focus on is what we get
It was clear that Amy had been traumatised by her experience of the mental health services. I would use the Rewind technique I described in my book PTSD Resolution to free her up from that trauma but, her this was just part of the film we would need to replay. Winding back the story, it was obvious she was only referred to the unit because of the self harm, and she was only self-harming as a response to the bullying she had endured from the age of twelve.
This was the extended traumatic period we would need to resolve, to reconnect her with the happier version of her former self before the bullying ever began.
But there was important, additional work to do. At the moment, and probably due to the anxiety and depression resulting from her extended trauma, Amy did not have any vision of her future at all. She had spent so long feeling anxious, down and depressed that she had disconnected with the hope of something better for herself.
As a result, she was entirely de-motivated about going to school. She just didn’t see the point. Amy had not yet connected the significance of her past to the present, and of the present to her perception of what lay ahead.
Connecting hope and motivation
After I used the Rewind technique to free her up from the past, we started work using the coaching ‘wheel of life’ to begin to formulate a positive picture of her future.
During the session, Amy became so much more animated and engaged. It looked like the Rewind was already working its magic and she was much more ‘present’. Her whole demeanour changed as we started to look at her future choices.
I asked Amy, ‘if you could have absolutely anything, and failure was not an option; if you had all the energy, resources and motivation, what is the future job or career would make you happy?’
Without any hesitation, Amy surprised me by responding ‘I’d like to do something similar to what you’re doing’ she said. ‘I’m really interested in psychology and I’d like to make sense of everything I’ve been going through.’
I could see that Amy had ‘got the point’ and her whole attitude changed in that moment. With my help, she began to make sense of her life by bringing together all the parts of her past experience like an amazingly complicated and intricate jig saw puzzle. And, in doing so, a clearer image of her present began to emerge.
Now we would need to ‘fill in the gaps’, searching together over the coming weeks, for the ‘missing pieces’ which represented all of the hopes, dreams and aspirations for a brighter future; the vision of which had eluded her for too long.
Trauma can rob us of hope if we don’t know where to get the right kind of help just when we need it.
