Systemic Practice in the High School

As a family psychotherapist in a child and adolescent mental health setting, I am interested in developing my practice into the community. I was initially inspired to take up family therapy after reading Minuchin’s Families of the Slums. Minuchin hoped that through his model of structural family therapy, workers could offer useful help to families in their community. I found the idea of community based workers supporting families very exciting and still do. The recent changes in family therapy thinking towards conversations and co-constructing with the resultant levelling of expertise has also interested me as being a more honest and open way of working.

One of the concerns I have heard from clients attending our clinic has been the worry of children missing time from school to come for therapy - particularly when the problem was a school based one or the child was behind in their studies. One option was to run an evening clinic, but this idea was not supported by our NHS trust, and in any case meeting in the evening has other disadvantages too. Another option was to see these children and families during school holidays but this would have meant long gaps between sessions.

For these reasons, and because I am a firm believer in providing mental health services in the local community, I decided to pilot a project where family therapy and systemic counselling could be provided within a secondary school. I had previously worked in a residential special school that took secondary school pupils who had emotional and behavioural difficulties. The aim of that school had been to return children back into mainstream education by working with local schools, through counselling and intensive family work. I have continued this interest by working in a local special school but wanted to see what potential there was for this type of service within an ordinary high school.

I chose this High School, because I had been working with a young man who was having considerable difficulties at school and home. I was asked to attend a case-conference at the school,and afterwards, the education welfare officer and deputy head expressed their concerns that in practice there is very little help available to families and children experiencing difficulties within the secondary school age range, unless these difficulties were extreme. By this time, it was often too late to bring about a resolution.

The project was approved by my clinic team providing the referred children had a mental health component to their difficulties (including family difficulties) and not solely school-based problems which should be sorted out by the education authorities. The referrals made have all been within our normal range of difficulties and have had a strong mental health component - see below for a breakdown of referral types. I met with the deputy head teacher of the school and they sought approval from the head teacher and year heads. They approved the project and it was set up.

Some of the concerns and benefits of running such a scheme were thought out and discussed within our team and at the school. The benefits revolved around:

• Children missing less school time and parents not having to take time off work to bring children to our clinic.

• It provided a less daunting setting place for parents and children than our mental health clinics (all children and families were given a choice between being seen at school or in one of our clinics - only one child opted to be seen outside the school and all parents chose the school setting, though in practice, we have ended up using a mix of clinic and school setting in many cases)

• It would aid clearer communication and the formation of more productive working relationships between our services, school teachers and parents.

• I hoped that such a clinic based in the school would raise awareness in school staff of mental health difficulties, would make it easier for staff and children to identify the mental health needs of children and to get help to them faster.

There were concerns were around confidentiality. These lay in the area of how children/parents would feel about being seen in their school (what if friends found out? etc.) and what information would be exchanged between our service and the school? Other concerns lay in the political arena such as how our role was defined in relation to educational psychologists, school doctors, school nurses, education welfare officers and special needs teachers. One issue common to many schools I work with, is the lack of sufficient input from educational psychologists. Whilst I am happy to provide the type of service I do, I would not want to ease the pressure on education authorities to provide a more thorough psychological service. I remind myself of what Haley said: that it is hard to be both a revolutionary and useful therapist and I also remind myself, that whilst we argue about politics there are families and children in distress who need help now.

The school took responsibility for selecting appropriate referrals, getting parental consent, informing and checking out with other relevant professionals about our involvement, collecting basic referral data and for providing a suitable room. The deputy head acts as co-ordinator in the school and all referrals through this scheme come directly to me. A commitment was made from our service to provide a half day per month to the school for seeing cases referred this way - though it has sometimes required more time. Children attending the school can be referred to our service through other channels as well and many are - such as via education welfare, educational psychology, social services, GPs, etc. These children and families can use the facilities at the school as well.

Our normal procedures were implemented in regard to confidentiality. We make it clear to parents and children that we are independent from the school (and social services) and information is only divulged with consent (except in very exceptional circumstances). In practice, confidentiality issues have not been a problem and where there is a school-based problem, the increased contact between school, family/child and myself has facilitated a healthy openness. Letters are only sent to other professionals with the parents/child’s consent and where these are not addressed to the parent/child then they are sent copies. In individual counselling with children, these sessions are confidential to the child.

So far this scheme is confined to one high school in our patch. There are not the resources within our service to extend it into other schools and in a political sense I hope this essay may encourage others to think about the development of mental health services within schools. In theory, some schools do have money to employ counsellors (and some do), but in practice the demands on money are so great that this sort of provision takes a low priority. One possibility may lie in joint funding between health and education for such a service.

Changes within the NHS and our own service may curtail this project or restrict such developments in the future as budgets become tighter and managers focus their workforce towards reducing waiting lists. This may leave us with little opportunity to develop into the community in a real sense and will mean less preventative work can be done to avoid the dangerous and escalating problems we often encounter. The fund holding system may mean that referrals become restricted to medical professionals and that we will no longer take referrals from education. As a service we have sadly stopped taking self-referrals.

Referrals from the High School

13 children seen in all, 9 boys, 4 girls

Two of the families had been referred to our service before but had not come. They preferred being seen at school.

Types of Problems (many were multiple)

Suicidal gestures/feelings 6

Challenging/difficult behaviour at home 7

Challenging/difficult behaviour at school 7

Family breakdown/repercussions 6

Significant peer relationship difficulties 10

Outcomes

Closed as 10/12/96 6

On-going 7

Come back if need to basis 1

Closed to mutual satisfaction 5

Closed because child/family did not come back 2

(2 children moved to other schools)

Type of Work Offered

Family therapy 9

Individual counselling 13

Case reviews/meetings 5

Total number of sessions approx.. 60

Total number of hours approx.. 70

Meetings, hours 4

Admin., hours 20

Future Developments

At a recent review meeting at the high school, several ideas and possible developments were discussed. The existing format was felt to be sound but the school were quite keen for various services to be made available to school staff. These included counselling for staff and discussion about handling difficult behaviour/children in the classroom. On reflection, I decided that unless these issues were connected to a particular child who had been referred, that this was a service that should be provided from within education, not from health. As a family therapist who believes in a holistic approach to problem solving, I could see the sense of the school seeking this help, but I had to consider the demand on our resources too, and these requests seem beyond what we can reasonably offer at this time. What these concerns do highlight, is the increasing emotional demands placed on teachers in our schools.

The school also suggested running some evenings classes for parents with a particular focus on managing difficult and challenging behaviour in their children. I agreed to do these. I wondered whether there was a role for a family therapist taking classes, or working together with teachers within the school to look at issues such as, relationships, parenting and the stresses of family life in general, covering aspects of the family life cycle and disruptions to it etc. The school are considering this.

One consequence of this development into the community has been to make me think more widely about my own work in our clinic. I am planning to set up adult and children’s groups (maybe not so focused on problems but on relaxation and social growth and development) and am also considering the development of a buddy scheme for teenagers and adults. Maybe there are resources within the high school to recruit buddies for some of the children we see in our clinic (or within their own school), and perhaps this community initiative will grow into something bigger and greater than either the school or our service can provide on their own?

 

Dennis Neill

Family Therapist

Family Therapy UK

1st May 2008