INTRODUCTION
The aim of this essay is to critically evaluate the theoretical and clinical underpinnings of the SPICC model. The learner will include a comprehensive analysis of the manner in which the contained models, Client-Centred, Gestalt, Narrative, Cognitive Behaviour Therapy and Behavioural Therapy relate to the process of therapy. The learner will include an in-depth analysis of the therapeutic relationship and clinical engagement as it applies to therapy with young clients using the SPICC Model. Ethical and practice considerations related to the therapeutic relationship will also be explored and critiqued before concluding the paper.
THEORETICAL UNDERPINNINGS
The SPICC model of practice makes use of particular theoretical models of well-established evidence based psychotherapeutic approaches. Drawing on concepts from Client-Centred, Psychodynamic Psychotherapy, Gestalt Therapy, Narrative Therapy, Cognitive Behaviour Therapy and Behaviour Therapy, these approaches are applied in a deliberately sequential process in order to help children move around the spiral of change (Geldard, et al., 2018).
Krueger & Glass (2013) contend that integrative approaches offer child therapists opportunities to “broaden their conceptualisation of presenting issue and strategically implement diverse intervention to address an array of challenges”. In conjunction, Geldard, et al., (2018) argue that randomly integrating various approaches can cause confusion and result in overall treatment programmes lacking clear direction. They believe that deliberately using planned sequential therapeutic approaches achieves significant advantages in therapeutic outcomes.
Geldard, et al., (2018) state that although some counsellors work under one particular therapeutic framework, that there is strong support in the literature for the use of integrative approaches. Contrary to this opinion, Fonagy, Target, Cottrell, Phillips, & Kurtz (2002) explain that despite the fact that more than 50% of child therapists utilise an integrated approach, there is little empirical research on integrative therapy for children. Produced in 2002, the learner considers this a valid explanation for the conflicting statements, however, in more recent years, Krueger & Glass (2013) concluded that “the overall scope of integrative psychotherapy approaches developed for children and adolescents is largely unknown because no systematic review of integrative treatment for youth has been conducted to date”. Despite this, Drewes, Bratton, & Schaefer (2011) maintain that it is “the diversity of clients and the consistently mixed results applying models to all people with problems pointed to the limitations of models that are too narrowly defined in theory and application”
Geldard, et al., (2018) explain that the SPICC model relies on two assumptions. The first being, if the therapeutic approach used is deliberately and purposefully changed at specific points in the process that the therapeutic change will occur more quickly, effectively and be more enduring. The second being to utilise some of the ideas, concepts, tenets, interventions and strategies of the aforementioned therapeutic approaches without having to accept any one theory in its totality. This assumption offers the therapist significant flexibility and an excellent opportunity for use of creativity and play using “miniature animals, symbols in the sand tray, storytelling and art” (Geldard, et al., 2018, p. 81). Conclusively, Corey (2013) explains that a significant challenge facing therapists is the delivery of therapeutic services in a brief, comprehensive, effective and flexible way and furthermore, that an integrative perspective at its best entails a systematic integration of underlying principles and methods common to a range of therapeutic approaches (Corey, 2013, p. 434).
The child’s internal processes of therapeutic change are referred to by Geldard, et al., (2018) under a model they developed known as the Spiral of Therapeutic Change, a key concept of the SPICC model. With the main purpose of developing adaptive functioning skills, the child travels through the steps in the process on the spiral. The overall process of change in this model is consistent with the stages in the counselling process of change as proposed by Watson and Rennie (1994). This cyclical process they refer to as a “continuous, dynamic and recursive feedback loop” and will be discussed further in the next section.
Diagram 1: Sequentially Planned Integrative Counselling for Children (SPICC) (Geldard, et al., 2018)
As human behaviour can be complex and children are diverse beings, only some parts of the spiral may be explored yet, some children may travel around the spiral more than once. Not indicative to all children, the spiral of therapeutic change offers a clear general understanding of the process of therapy and it’s cyclical and flexible nature is appealing as it can be adapted to suit the complexities of children’s issues. This quality could be referred to as yet another strength of the SPICC model and indicates that it is dynamic and process-driven. “The Spiral of Therapeutic Change” also displays a brief solution focused core, which could be considered valuable when working with children in terms of time-constraints and cost-effectiveness. Geldard, et al., (2018) also describe the Spiral of Change as a helpful tool for evaluating progress.
“The majority of child and adolescent integrative programs (CPP, TST, TF-IPT and PCIT etc.) have been designed to address specific disorders” (Krueger & Glass, 2013, p. 336), including traumatic stress, ADHD and anxiety. Krueger & Glass (2013) report that extensive research including randomised outcome studies have been conducted to demonstrate the effectiveness of a number of therapies, but by no means do all have evidence base to date. And although psychotherapy integration is an essential part of child and adolescent treatment, a limitation of the SPICC model appears to be lack of significant empirical research in the field. Furthermore, although the model contains well-established evidence based psychotherapeutic approaches, the appropriate transition between the stages is considered vital for the therapy to be effective. Geldard, et al., (2018) state this model is appropriate for use with trauma, yet a percentage of children who present with significant trauma or other more complex issues that may require more long-term help. Moreover, the expectation that the therapy should be relatively short-term may cause some counsellors to feel under pressure and move the therapy along at a pace that is more suited to their needs than those of the child.
The sequential nature of the SPICC model offers the therapist a solid framework to work within, however, a natural bias or significant training in one school of psychotherapy, may cause challenges. Although appearing easy to apply, lack of confidence in one area/contained theory might compromise the process. Additionally, the learner believes that a detailed knowledge of each approach with the necessary skills to implement them is vital to its efficacy.
THE STAGES OF CHANGE AND THE PROCESS OF THERAPY
To enable the child to tell their story and accompany them through their exploration of free/meaningful play, the counsellor must provide or create an effective and trusting therapeutic relationship. The use of appropriate media, facilities and appropriate child-counselling skills are key ingredients of this process. Addressing issues regarding resistance and transference, the counsellor will also regularly re-evaluate the appropriateness of the types of media used and make changes when needed (Geldard, et al., 2018).
Lane, Ryan, Nadel, & Greenberg (2015) contend that since Freud, clinicians have understood that disturbing memories contribute to psychopathology and that new emotional experiences contribute to therapeutic change. However, they insist that significant controversy still surrounds what is truly necessary to bring about therapeutic change. They express that empirical evidence points towards emotional arousal and memory as key components “but the specifics of what it is about emotion that actually brings about change are not clear” (Lane, Ryan, Nadel, & Greenberg, 2015).
A clear understanding of change processes relevant to counselling children is essential in understanding SPICC. Most of the literature is concerned with counselling adults, but the theories described also have relevance for children when they are sequentially integrated into an overall change process.
According to Geldard, et al., (2018) the stages in the process of change are consistent with the stages of the internal processes of change in a child. Initially, the child is offered an opportunity to join with the counsellor and begin to tell their story. During this relationship-building phase, with the goal of enabling the child to talk freely and feel valued and respected, the PCT approach is utilised in order to provide a warm, empathic, comfortable and safe environment. Bright (2015) contends counsellors working with children must appreciate the particular needs of these age groups to become attuned to the appropriateness of language and expression. As this approach seeks to put the client as the centre of practice, the therapist relates to the child non-judgementally, with congruence and unconditional positive regard (Bright, 2015). By joining and connecting with the client, the therapist develops the therapeutic alliance. Concomitantly, “person-centred practice provides space for being and exploring; for children and young people these processes take on a variety of expressions. Children symbolise their inner world via creative media like play, art, puppetry, stories, sand-play, dressing up and music (Bright, 2015, p. 28). Furthermore, Geldard, et al., (2018) agree that it is observation of the child that informs the therapist about possible internal processes occurring and this can provide a guide for future exploration.
During the second phase the counsellor focuses on the child’s experience and the child continues to tell their story. Geldard, et al., (2018) suggest Gestalt Therapy as the most appropriate approach to promote change at this stage. Focusing on experientially exploring the child’s internal and external worlds, the same author posits that change occurs as a result of raised awareness. Through articulating the experience in words, the child’s awareness of the issue increase and enables them to get in touch with emotions. Oaklander (1997) informs us that most children will be resistant to some degree. Honouring the child’s resistance is crucial and she identifies this as a form of protection. Exploration through stories, art and other forms of play with the therapist help the child to define the self and achieve mastery, enabling the child to feel a sense of power and control.
As the child explores their view of themselves in phase three, a cognitive shift occurs in perception, enabling them to confront self-destructive beliefs, encouraging acknowledgment of choices and options. Developing another view of themselves offers an ability to improve their self-image. During this phase, the SPICC model uses Narrative Therapy, a concept based on “storying”. Scaletti & Hocking (2010) explain that “stories convey complex meanings and facilitate understanding of human experience”. Corey (2013) contends that one of the main tasks of narrative therapy is for the therapist to help the client in constructing a preferred storyline, helping the client to envisage possibilities for the future. Using creative media (clay, sand tray, art etc.) and storytelling acts as a method of supporting children to tell their story, eliciting their interpretation of events and assisting them to make sense of their experience (Scaletti & Hocking, 2010).
Cognitive behaviour therapy encourages the child to identify and challenge unhelpful thoughts and processes and is the preferred method of change at phase four. McLeod (2013) describes the approach as less concerned with insight and more oriented towards client action to produce change. It is ideal for use from the age of seven, when carefully adapted to the developmental level of the child. For younger children, more visual and less verbal techniques are required. Stallard (2015) describes this model as an evidence-based approach. Arnberg & Ost (2014) agree that regarding treatment of children with depressive symptoms, CBT is the only treatment for which there are several studies of its efficacy. The Geldards recommend this approach during this phase, as the child can be supported and encouraged to learn new ways of thinking with the aim of reducing emotional distress and maladaptive behaviour. They believe that without this cognitive restructuring phase, that the child would likely repeat past behaviours and therefore remain emotionally traumatised.
And finally, phase five involves the child exploring newly acquired behavioural experiences utilising new skills. During this phase, the child will evaluate new behaviours and is given the opportunity to rehearse these with the therapist. “By adopting motivational and incentive strategies (rewards or consequences), “the child is able to change and generalize new skills to the wider social environment” (Geldard, et al., 2018, p. 83).
Because each therapeutic approach suggests a particular theory of how change occurs, Geldard, et al., (2018) argue that “its seems logical to apply these theories to the relevant stages in the counselling process so that the needs of the child are fully addressed”. Furthermore, they convey that ‘using strategies and techniques from each of the mentioned approaches at specific points in times enable the child to move freely around the spiral” (Geldard, et al., 2018, p. 79).
RELATIONSHIP FACTORS
“Nothing happens without at least a thread of a relationship. The relationship is a tenuous thing that takes careful nurturing. It is the foundation of the therapeutic process and can, in and of itself, be powerfully therapeutic” (Oaklander V. , 2007)
There is a deep abiding belief in the central role that the authentic relationship plays in the therapeutic process (Mortola, 2014). According to Mortola (2014), without “a thread of a relationship being established between the child and the therapist, no therapeutic work can happen”. The therapeutic alliance indicates the degree to which the child or adolescent believes and trusts in the counsellor (Prever, 2015). The alliance may be established in a first session but usually takes a period of time, continuing to develop and deepen as the relationship grows. Prever (2015) argues that the concept of therapeutic alliance did not begin with Rogers, but has its roots in psychoanalytic theory. Stretching back as far as Freud, Prever (2015) suggests that the working alliance in therapy was comprised of three goals; tasks, goals and bonds. As cited by Prever (2015), Bordin describes the therapeutic alliance as “an essential component in counselling and possibly the most important factor in bringing about change in the client”.
Prever (2015) states that themes relating to the goals described above, are well developed in the person-centred literature, where it is obvious that the client’s attitude towards the counsellor is considered important. Oaklander (1997) reminds us that trust and feelings of safety are crucial to the development of the relationship and that the therapist is authentic and genuine, does not manipulate or patronise, is non-judgemental. She maintains that finding creative non-threatening ways to the reach the child is a key task of the therapist and that there is a natural progression “a very definite process” when working with children. Virginia Axline’s basic principles of non-directive play therapy indicate that a warm friendly relationship with good rapport is essential, as is the therapist being accepting of the child exactly as they are (Axline, 1989). In conjunction, Geldard, et al., (2018) describe the relationship as a connecting link between the child’s world and the counsellor. The relationship comes first and that in fact for many children, the focus of the therapy becomes the relationship (Oaklander, 1997). Working within the child’s frame of reference informs the therapist how the child views their environment. Empathy and trust are highly valued by young people and act as bond indicators however, an additional parent support dimension is of particular importance, especially where the counsellor is able to show understanding, reassurance and support (Prever, 2015).
By providing an exclusive relationship between the therapist and child, the child will feel accepted and uninfluenced by the views of the parents. That said, most children are brought to therapy by their parents. Creating a friendly and hospitable environment can encourage the parents to feel welcome and valued when they arrive. This is central to joining with the child but is also part of the therapeutic process (Geldard, et al., 2018, p. 60). Oaklander (2007) believes that “the first meeting is an important one”, as it offers a sense of the dynamics of the parent-child relationship.
Narrative conversations give power to parents, “it is important to give parents the space to examine and reflect on what is important to them before asking them to make choices about future action such as a specific intervention” (McQueen & Hobbs, 2014, p. 16). By collaborating with the parents, the values, knowledge and skills of the parents can be explored and provide the therapist with an understanding of how change could happen. Opposingly, Landreth offers a very different view on parental involvement stating “the presence of the parent in the playroom can severely restrict the development of the relationship between the therapist and child and the presence of a parent in a play therapy session should be a rare occasion” (Landreth, 2011, p. 319).
The research concludes that including the parent when working with children appears to be viewed differently according to each modality. Yet, it has also become evident that it is difficult to envisage the establishment of any successful therapeutic alliance with child or parent, without the presence of Roger’s core conditions. Concomitantly, Ackerman and Hilsenroth (2001) describe attributes of a counsellor that could hinder the therapeutic alliance as ‘rigidity; uncertainty; being critical; distant; tense and distracted”. Techniques have also been identified as important in alliance development and it was noted that sessions being over-structured, inappropriate self-disclosure, overuse of transference interpretation and unhelpful use of silence can interfere with the therapeutic alliance (Prever, 2015). In terms of monitoring the health of the therapeutic alliance, regular reviews are useful and provide important indications of progress, helping to identify if the child’s needs are being met. However, Prever (2015) suggests that emotional and feelings levels are not always measurable at review and certain measurement scales may not necessarily be the best indicator of effective counselling. The effects of counselling are not always immediate and are often used as a personal resource in years to come; reviews should be used with caution and in the context of the wider counselling work.
Research indicates that there appears to be significant differences between therapeutic work with children, young people and adults. Ingram & Robson (2015) outline them as different stages of development, emotional, moral, physical and cognitive, ethical and power issues. Oaklander (1997) suggests that working with children happens in smaller sections and that resistance is a relationship factor with children that must be honoured. She believes that adults can handle much more than children. In relation to questioning, some children require prompting, and Oaklander (1997) believes that children don’t respond as adults would to questions such as what are you feeling? Oaklander (1997) believes the focus to be on awareness with adults, yet with children she emphasizes it is more about the experience. She also identifies that paying attention to the self is paramount with children, in order to give them experiences with their senses and body and an opportunity to gain mastery and control in an effort to strengthen the self.
ENGAGING CHILDREN, ADOLESCENTS AND PARENTS
Counselling children can be challenging for therapists whose training has focused on adult. Van Velsor (2004) contends that in acquiring basic skills, therapists learn to use micro-skills or “communication skill units” that help them act more purposefully with their clients. Such skills she describes as “relevant to children” and include reflecting client content and feeling as well as reflecting meaning, interpreting and making use of metaphors. The application of these skills would include the acknowledgment of the child’s cognitive, emotional and psychological uniqueness (Van Velsor, 2004). Concurrently, Ingram & Robson (2015) state that even though specific approaches will have particular skills sets, the four broad areas of attention-giving, observing, listening and responding are the basis for therapeutic work with children and adolescents. Yet they too contend that the fundamental issue is how these key skills are adapted to meet the unique needs of the child/adolescent.
Particular counselling skills are relevant for the different stages of the therapeutic process (Geldard, et l., 2018). The different counselling functions of the therapist are joining with the child, observation of the child, active listening, awareness raising and the resolution of issues to facilitate change, dealing with the child’s self-concept and destructive beliefs, actively facilitating change and termination of counselling. The skills of the therapist should enable the child to tell their story and get in touch with strong emotions whilst dealing with resistance and transference. Particular qualities/attributes that the child therapist requires are congruence, being in touch with own inner child, being accepting and being able to emotionally detach (Geldard, et al., 2018). West (1996) also agrees there are a number of necessary attributes including, being able to relate to, through and with feelings. Understanding and coming to terms with issues in their own childhood adolescence and parenting life, working within a child-centred framework, communicating with children, playing, working alongside troubled children without being damaged by their pain and acting as an advocate for the children they have in play therapy. The learner found it interesting that creativity was not mentioned as a valuable attribute.
An understanding of the developmental stages young people grow through are fundamental to implementing the SPICC model successfully. Ingram & Robson (2015) believe culture may have an impact and they suggest that remaining open, curious and in a culturally pliable position is vital in terms of working with this challenge. Adhering to boundaries and the normal adult limits of confidentiality runs the risk of alienating the parent. The relationship between child and counsellor can be threatening to the parent, developing effective communication skills with the caregiver is essential, keeping them involved without violating privacy. Ingram & Robson (2015) suggest that involving the caregiver encourages a positive relationship.
Increasing pressure of time and cost has resulted in rise in popularity of time limited counselling. The learner contends that this aspect of the SPICC model can be identified as both a strength and limitation. The cost effective benefit is appealing, yet it has to be asked what quality of work can take place during this time? Will the pressure on the therapist to solve the problem impact the building strength of the relationship? Nevertheless, Feltham reasons that all counselling is time limited in one way or another (Feltham, 1997).
The learner agrees with Sinitsky (2010) that engaging in collaborative therapeutic relationships, where values and beliefs are respected and by incorporating a reflexive practice whereby we continually ask questions about our role in the therapeutic work, can we develop our understanding of the subjective experiences of children/adolescents in the context of their social, cultural and family environments. Furthermore, in the context of engaging with children, the learner believes that therapeutic possibilities are enhanced by the sensory nature of creative work as it enables the therapist to connect with the imaginative essence of the child’s world. Engaging young people means communicating in ways that they understand and enjoy.
“Imagination is more important than knowledge.” – Albert Einstein
ETHICAL AND PRACTICE ISSUES
There are numerous complex ethical and unique legal concerns to be considered when counselling children. The competing interests of parents, children as well as other stakeholders creates significant challenges in terms of privacy, confidentiality and legal privileges (Ford Sori & Hecker, 2015). According to Geldard, et al., (2018) one of the most confounding ethical issues that counsellors face when seeing children is what and how much information to share with parents, an issue that can greatly impact the course of the therapy. Ford Sori & Hecker (2015) tell us that as well as sourcing signed consent for the child receiving treatment, it is also imperative to obtain written proof as to who has legal custody of the child. Whilst Geldard, et al., (2018) convey that it is obtaining the child’s consent that is equally as important. They contend that by doing so offers the child a voice and encouragement to feel respected and valued in the process.
Informed consent, confidentiality, including family members and connecting with associated parties are important ethical considerations (Geldard, et al., 2018). However, these complex issues often present without a clear answer. In this instance, Geldard, et al., (2018) suggest seeking advice from relevant ethical codes and guidelines as well as a supervisor. Confidentiality when working with minors can present many ethical issues therefore, it is crucial at the contracting stage all concerns relating to confidentiality are addressed and explained clearly. For instance, “practitioners have a responsibility to inform their clients in relation to the limits of confidentiality, including statutory reporting obligations with regard to child protection issues” (IACP, 2019). An alternative code of ethics in Ireland is provided by The Irish Association of Play Therapy & Psychotherapy (IAPTP), a professional body for Play Therapists & Psychotherapists (IAPTP, 2019). In terms of confidentiality, the IAPTP Code of Ethics 4.7, suggest that discussions regarding confidentiality should take place prior to counselling taking place.
During the child-counsellor relationship, Geldard, et al., (2018) describe maintaining boundaries, power imbalances and roles and responsibilities of the therapist as ethical considerations. In terms of boundaries, Oaklander (1997) believes that setting clear limits benefits the child allowing them to know and test their own boundaries, stating that lack of clear boundaries may make a child feel anxious. Geldard, et al., (2018) set down three basis rules at the outset, the child is not permitted to injure themselves, the counsellor or to damage property.
Child welfare and protection policy is based on a legal framework provided primarily by the Child Care Act 1991 and the Children First Act 2015. The Child and Family Agency in Ireland, knowns as Tusla, is now the dedicated State agency responsible for improving wellbeing and outcomes for children. The Children First Guidelines are intended to assist people in identifying and reporting child abuse and to improve professional practice in both statutory and voluntary agencies and organisations that provide services for children and families (An Tusla, 2019). In 2010, The National Executive Committee of IACP adopted the Children’s First Guidelines of the Department of Health and Children as part of the organisations policy. Non-mandatory by law, it is IACP’s policy that members act in accordance with them.
CONCLUSION
Throughout this essay, the learner provided a critically evaluation of the theoretical and clinical underpinnings of the SPICC model. A comprehensive analysis of the manner in which the contained models, Client-Centred, Gestalt, Narrative, Cognitive Behaviour Therapy and Behavioural Therapy related to the process of therapy was provided. The learner included an in-depth analysis of the therapeutic relationship and clinical engagement as it applies to therapy with young clients using the SPICC Model. Ethical and practice considerations related to the therapeutic relationship were explored and critiqued before concluding the paper.