“Counselling is not a judicial process. Instead, clinicians are entrusted to protect a safe clinical context, for both youth and the referrer alike.”

Itamar Danziger in his article for the eastern branch Spring Bulletin theme of Children and Youth (found in http://www.oasw.org/media/184971/Spring2014EBBulletin.pdf) brings us to reflect on the challenges youth face in being referred to counselling and the challenges we face as clinicians. I found how Itamar framed the context of referral ringing true, with empathy for both sides of this challenge, along with setting constructive directions.

Some youths find themselves in difficult binds. On one hand, they can have many internal and external circumstances to cope with, compounded by an increasing urge to be proactive in their own lives. On the other hand, those youth may not have as much power to do so as they wish, understandably or not. Adults can choose and influence their environments much more freely than youths can.

Society and its various systems (schools, family, justice, youth protection systems, etc.) dictate social axioms and expectations. When those axioms collide with a particular youth’s disposition, those systems may go into enforcement mode, often more so than they would with adults. When this mode fails, the youth might be referred to counselling to “address his/her issues”. Such referred youths are often hesitant clients. They may nominally agree to the counselling which they were (assumedly politely) coerced into, and say all the right things in session.

These “ideal” clients will “recover” from their “clinical issues” as soon as they have convinced the referrer
of their engagement in counselling, despite too often having internalized the external issues, while feeling pathologized. Soon after the termination of the successful pretend therapy, the same youth may be pressured into more counselling, restarting the
referral-pretend therapy cycle.

Unfortunately, compliance and camouflage are not resolution. The presented clinical concern (whether affective or behavioural), or the youth’s resistance, may be the only means of giving voice to the underdog’s side of the client-referrer rift.

Thankfully, other coerced youths are more honest. They tell the intake worker that they are uninterested
in counselling. They may also offer their opinion of the referrer, mere milliseconds before hanging up the telephone on the intake worker.

In the above-mentioned situations, the youth are in a power struggle with the referring party over the nature of the presenting issue. The youth may win or lose that power struggle, but unless those youth make it into real clinical work, the concerns underlying and beyond the power-struggle may never be clarified, or resolved. Regardless, the referrer may defer, but never wins the wars over intentions and narrative. If pretend therapy is the pinnacle of sublimated resistance, it is seconded only by counselling refusal, or no-shows.

Worse yet, affective and/or behavioural responses to a youth’s sense of being mis-attuned to, coerced, or pathologized often beget labels such as, “it’s just an excuse”, “he’s resistant”, “she just wants attention”, “he’s controlling”, “she’s not ready for therapy”, “he has little insight”, etc. Such labels have not cured any client. Those damning comments are mere pseudo-clinical blabbing and do not address the immediate dynamics between referrer and client. Being aware of such systemic implications should be obvious to
social workers.

So, are the presenting issues justifiable? Or is the referral justified? Are various shades of mandated counselling for youths appropriate? And who is right — the referrer or the youth? Those questions are, and should remain, clinically irrelevant. Counselling is not a judicial process. Instead, clinicians are entrusted to protect a safe clinical context, for both youth and the referrer alike.

Discussions around the power dynamics of a referrer-youth rift need to be the first clinical goal. Such an approach promotes a higher chance of engagement, consequent departure of power struggles, and into
real clinical work. Not doing so makes the therapist another coercing, damning, rejecting authority figure, thereby further entrenching the original issues.

Some of my favourite opening questions for coerced clients include: “So, who wants you to go into counselling the most? Why do you disagree? And despite this, why did you agree to come and talk with me? Is the presenting issue about X for you, and not
as Y’s narrative dictates? How do you manage those differences? What would be the risk/cost of you going to counselling given this situation (or not go to counselling, for the overly agreeable)”.

Précis : Le présent article encourage les travailleuses et travailleurs sociaux à se sensibiliser aux éventuelles considérations dynamiques et systémiques lorsqu’ils travaillent avec des jeunes qui hésitent à aller voir les professionnels vers lesquels on les oriente, du fait que d’autres s’intéressent plus qu’eux-mêmes aux services cliniques. L’article offre également des suggestions relatives à la participation de ces jeunes.

Itamar Danziger is the intake worker and a counsellor at the Child and Youth Counselling Services – part of the Children’s Mental Health Programs at the Cornwall Community Hospital (in Cornwall Ontario). He is also works in private practice in Cornwall.