This report describes Flourish’s pilot project to explore the integration of psychotherapy and advocacy to help highly-challenged families.
Introduction
The aim of this project, which is in its pilot stage, is to evaluate whether the integration of counselling[1] and advocacy could help highly-challenged parents (who are currently unable to access or benefit from existing services) towards better mental health, life functioning and parenting, thereby helping the children and wider family. The rationale for integrating therapy with advocacy is that the plight of such parents derives from complex interplay between psychological factors and environmental factors, such that progress towards an overall resolution requires near-simultaneous attention to both. Otherwise, psychological factors prevent resolution of practical difficulties, and vice versa.
This pilot project is not a formal trial of the approach (which has in any case not been standardised). Rather it is an exploration of the principle of integrating therapy and advocacy with the aim of understanding the success factors, the difficulties and the overall effectiveness of the approach. This report might best be viewed as an aggregation of anecdotal experiences[2], which should form the basis of a later, more structured evaluation.
The Integrated Therapy and Advocacy Approach (ITA)
In brief, the approach involved the application of psychotherapy and advocacy, either by the same professional – a therapist trained in advocacy (Model 1); or two different practitioners – a therapist working very closely with a trained advocate[3] (Model 2). Model 1 was applied to parents of neurodivergent children; Model 2 was applied to more general presentations. For both models, referred clients were recruited into the pilot after provision of an explanation of the experimental approach and receiving full consent (most clients were very positive from the outset and helped shape the offering). Referrals came either from a school or from a collaborating charity.
Sessions were mainly held weekly as a default, but the timing and length of sessions varied greatly and was strongly dependent on the client needs and disposition at any one time, and on the timing of progress in resolving practical difficulties. We believe that this flexibility and person-centred ethos is crucial, at least in the early sessions when client functioning is compromised.
A full description of clients’ psychological backgrounds and challenges is hard to provide in a short report. In what follows, clients typically have some combination of these challenges:
- Being chronically overwhelmed by challenges
- Multiple adverse childhood experiences (ACEs)
- Not getting help from statutory bodies
- Longstanding low self-esteem
- Not being taken seriously
- Inability to secure help for neurodivergent child
- Intolerance of diversity in society
- Serious progressive illness (and inadequate support)
- Living in unsuitable accommodation
- Feeling unsafe due to neighbours
- Coping with indifference and judgement from helping agencies
- Inadequate financial resources
- Poor experiences of being parented as children
We intend to develop an analysis of the practical and psychological challenges which considers the relationship between the parent and the external world in a holistic, relational way; rather than attributing blame to one party or another. In the absence of this, the above list is purely indicative.
Findings to Date
All the clients have been helped towards a better level of psychological and practical function, with concomitant benefits for the children, as assessed by the clients themselves and other professionals with whom they interact. In most cases, substantial improvements are seen after only a small number of sessions (five or fewer). We have found no support for the commonly-held notion that such parents are beyond help because of their inherent character. Rather we find significant improvement in self-sufficiency, in that the parent can more readily speak for themselves and engage more productively with helping agencies.
The parents’ presentations are diverse and often complex: it quickly becomes evident how standardised service provision has left them unhelped. The ability to unravel the psychological and the practical issues is valued and substantiates the rational for ITA. Other aspects of the ITA ethos – person-centeredness and flexibility – are also clearly important and valued.
Despite the examples of success of the ITA approaches, we should mention some challenges. Firstly, the work can be particularly emotionally demanding, requiring experienced practitioners and higher levels of support and self-care. Secondly, the flexibility that is inherent in the model (at least for optimal results) does make scheduling and time management more difficult (although manageable). However, we believe that the higher level of investment that these two challenges entail pays off handsomely in terms of both the emerging quality of family life, and its expected life outcomes for the children, and in terms of the associated saving in downstream expenditure by the state.
Conclusion
The work so far has further shown how the practical and psychological issues faced by highly-challenged parents are intimately interwoven, and that a parallel interweaving of advocacy and psychotherapy is very effective in resolving those issues, to the benefit of the family as a whole. The work is ongoing and we seek to expand the range of client presentations and settings in the coming year.
Case Studies[4]
Jenny came to the project (Model 1) for help with her autistic son. She reported high anxiety, chronic overwhelm, and feelings of failure – all of which resulted in an inability to take action. Her local education authority (LA) had refused to assess her child’s need for an Education Health Care Plan (EHCP) – despite having a diagnosis – and, due to Jenny’s ADHD, she had not challenged this decision within the timescale allowed.
Working with the therapeutic advocate, Jenny was able to explore her fear of failing her son which was holding her back. She was able to connect this to her own childhood experience of being an undiagnosed neurodivergent child and her parents’ inability to understand or advocate for her. Alongside the therapeutic support, the therapist-advocate shared research into the statutory requirements of the LA which weren’t being fulfilled, and wrote a supporting letter which Jenny used to successfully access the Needs Assessment that had been previously denied.
Having moved her son’s case forwards, Jenny felt lighter. She was then able to make medical appointments for herself to address the multiple health issues she had been ignoring. She has begun to talk more about the impact her own childhood experiences have on her current parenting challenges, leading to a greater self-acceptance and ability to cope. In her feedback, Jenny said:
I wholeheartedly believe that without this help my mental health, as a result of the EHCP, would still be awful. Which understandably has a which has a huge impact on my son. And on our family life. It has made such a positive difference to our quality of life, having this support. Things just feel a lot more positive now…Sincerely. Thank you, from me and my family. I have felt truly supported and a lot less on my own.
Maggie and her two children, Alex and Jamie, were living in temporary accommodation following her domestic abuse. Maggie’s anxiety had escalated and she had found it difficult to leave their accommodation, other than to take the children to school which was often fraught and resulted in late attendance. She also suffered from a health condition and was undergoing further tests.
Maggie was referred to the service (Model 2). On initial contact, she was highly anxious about accessing support because of her limited capacity to travel to venues. As a result, a room was secured near her accommodation and Maggie was able to meet with the team in person.
As a consequence of Maggie’s and her children’s circumstances, there was already some professional support in place. Maggie’s heightened anxiety prevented her from ‘keeping track of where things were up to and who was talking to who.’ The advocate was able to liaise with the professionals and update Maggie on how things were progressing. The advocate also supported Maggie in completing an application for additional financial support, which was successful.
Maggie accessed therapy and spoke in depth about her past experience of domestic abuse and current fears for her family. As a result, although Maggie still struggles with her health and her situation, she has greater self-confidence and greater ability to engage with helpers. Her feedback included the following:
It’s really good having you both working together. There’s lots of people working with me but sometimes it’s like no one’s talking to each other. This service has been very helpful especially because I can’t travel anywhere…well…because of my condition. The advocate has helped me so much. She sorted my applications and made it all work. Also, having someone of my own to talk to has really helped me especially with everything that’s happened. Talking helps me make sense of things and makes me feel better in myself.
Interim Report by:
Della Austin[5] (Project Director)
Dinah Purton (Project Director)
19th January 2024
[1] We use the terms ‘counselling’, ‘psychotherapy’ and ‘therapy’ interchangeably.
[2] For a therapist to introduce an element of advocacy into their counselling is unconventional but not unprecedented. This report also draws upon five instances which the authors have experienced prior to the formation of Flourish. Examples also exist in the literature; see for example Davies, J. (2021), Sedated: how modern capitalism created our mental health crisis, London: Atlantic, pp. 280-284.
[3] Our specification for an advocate is a professional a) with experience of dealing with vulnerable adults, b) who has completed advocacy training, and c) can confidently take action on a wide range of practical issues.
[4] These case studies are highly-anonymised to avoid identification and the client’s permission to use the studies has been obtained.
[5] Corresponding author. Email: della@flourish.org.uk