Safety issues in the therapy room
Roger Day
As a psychotherapist and play therapist using 'talking' therapy and play therapy with children and young people, I am well aware of the importance of safety in the therapy room.
It is, of course, vital that I ensure my young clients are safe. But what about me as the therapist? What protection is there in place for my own safety, particularly in my private practice work? In this litigious society it is especially important for a man on his own with small children to ensure that he is working safety and ethically – and that he is seen to be doing so.
Over the years I have developed a number of safety strategies in this area:
1. Regular police check
While not a fool-proof method, police checking ensures that the individual is at least being willing to be open and honest about past and present criminal convictions. For many years, however, the therapist in private practice had great difficulty in getting a police check. The therapist had to be working for an organisation such as social services in order to get one. Under the Criminal Records Bureau (CRB) system it is now possible for any private individual to request an enhanced check through one of the CRB umbrella organisations. I make sure I get my enhanced CRB updated regularly. For details look at the CRB website:
www.crb.gov.uk
2. Someone else around
It is never a good idea for a therapist to be in a building on his own with a client, child or adult. In my private practice work with children I seek to ensure that someone else is always there. This could be a parent waiting for her child, a fellow therapist or even the cleaner. If that person is aware that therapy is going on, he or she can be attuned to any difficulties and available in case of problems.
3. Boundaries around touch
For many years I have believed that touch is important in working therapeutically with children. However, the type and extent of touch needs to be agreed in advance with the child's parent/carer. It could be hugging, touching a shoulder or just holding hands. It could also be tickling or even play fighting. In addition to agreeing the extent of touch in advance, each time touch is appropriate in a session I ask a question of the child, for example: 'Do you want a hug?' or: 'Would you like me to hold your hand?'
It is also vital to have ground-rules. Children are taught at school that touch in 'swimming costume' areas of the body is abuse. I would go further by suggesting that touching the leg above the knee is also not acceptable. As a man working with children I never sit a young client on my lap. I also avoid face-to-face hugging of a girl who has begun to develop. This can include some girls as young as nine. Instead, I use a 'sideways hug' that satisfies the older girl's need for closeness and avoids inappropriate physical contact.
4. Working with survivors
When I work with young survivors of abuse who may be called as witnesses I take into account the guidelines of the Crown Prosecution Service (2001). This means avoiding talking about any details of the abuse that may affect the outcome of the case.
Details of abuse are not always necessary, even if there is no prosecution being taken. The therapist who insists that a child talks about – or draws or acts out – the abuse could be seen as perpetuating it. I encourage the child to do, say or play in ways that he or she wants. This avoids any hint of encouraging 'false memory syndrome'. Sometimes children (and even adults) can work through the issues using anger expression and other forms of play without any recourse to talking about the abuse.
For some clients who have been abused any form of touch is inappropriate, however upset the child. I am thinking particularly of a child who has been abused by a succession of men. Having another man touch him or her, however carefully and ethically, is probably the last thing that child needs right then.
5. Door open or closed?
Almost all therapy takes place in a room with the door shut. This is standard practice for most therapists. There are instances, however, when leaving the door slightly ajar can be therapeutically justified, even if it means compromising confidentiality by risking someone overhearing what is happening. The child with extreme anxiety or claustrophobia is a case in point. So too is the child who has been subjected to sexual abuse behind a closed door, such as a bedroom or bathroom. In these instances, not only does the client feel safe but the therapist can feel less vulnerable.
6. Permission to leave the room
I expect my child clients to stay in the room throughout the session. In some cases, such as children who run away or leave school without permission, I establish a ground rule of not leaving the room at all until the session has ended. With this in mind, I always ensure that my younger clients have been to the toilet before the start of the session. This makes it more likely that they can last through the session without having to leave the room. There are a few exceptions to this rule. These include children who have experienced being locked in their bedroom as a punishment and those who have not been allowed out of a room until they have engaged in a sexual activity with an abuser. In these rare instances I give the child permission to leave the room as often as she/he needs to. One 10-year-old I worked with would visit the toilet three or four times in a session and this permission-giving allowed her the space she needed to do very effective therapeutic work.
7. Tape recording
When I work therapeutically with a child on her/his own, I record the session. I agree this in advance with the parent/carer and child and explain that the recording is for my note taking and is kept in a locked cabinet. It is available for loan to the carer only with the clear agreement of the child. The recording also provides a back-up for me should any allegation of misconduct be made by a child or parent/carer. Recording play sessions has, of course, a long and distinguished history going back to Axline's early work (see Axline, 1947/1989; Axline 1964/1990).
8. Involving parent/carer
Since most issues with children impact on and are affected by the system (family, school, etc), I believe it is perfectly appropriate to involve the parent, foster carer or social worker in some or all of the sessions. Having another person present, providing it is therapeutically justified, is a major contribution towards safe, ethical practice. It is especially important with the child who is either flirtatious or is known to be acting out sexually.
The above list of safety measures may at first appear somewhat defensive. I make no apologies for that. My justification for it is that not only do I feel safer and less vulnerable to allegations, but my child clients intuitively feel protected.
Axline, Virginia (1947, revised 1989). Play Therapy. London: Churchill Livingstone.
Axline, Virginia (1990). Dibs: In search of self. London: Penguin Books. (Original work 1964.)
Crown Prosecution Service (2001). Provision of therapy for child witnesses prior to a criminal trial: Practice guidance. London: CPS
Roger Day PTSTA, Certified Play Therapist is a UKCP Registered Psychotherapist specialising in therapy with children, young people and families.