Editorial

You will notice that this is a slim issue, which is because we needed to tighten our belts for the last issue of this volume, after producing two larger than usual issues earlier in the year. This issue is particular in that it is made up of two collections of papers. We have three papers that were originally given at the 2021 ACP conference on ‘Modern families: working with and thinking about neglected and vulnerable children, parents and families’, and we have four short papers that were originally given at a symposium on the challenges of ethical publishing in the digital age, held in March of this year.

The 2021 ACP Conference was also a very particular conference. It was the first to be held online, and had been postponed from 2020. At that time, we had hoped in vain that the conference might be held in person, if we waited until 2021, but the pandemic kept its hold and it became clear that would not be possible. There were concerns about the loss of an experience of coming together, in the same physical space, to process our shared experience of exploring the theme in relation to one another. Diana Cant and Alison Roy harnessed their tremendous liveliness and creativity to write poetry, in real time, in response to the presentations, performing it for delegates before the ink was dry on the page, as it were. This offered delegates one way to enliven our emotional connection with what we were all remotely engaged with. (ACP members can access some of that poetry presented at the 2021 Conference, here at: https://childpsychotherapy.org.uk/members/acp-conference-2021-poems).

The first two of the three papers from that conference in this issue are about children who are not cared for by their birth parents. The first is ‘Kinship care: Uncannily close for comfort?’ by Deirdre Ingham and Julia Mikardo. Using clinical vignettes, the authors offer a critical evaluation of the policy of placing children in kinship care, which tends to be preferred whenever possible. While the potential benefits of this policy are acknowledged in the paper, the authors highlight the ways in which: ‘The struggles associated with kinship care are not separate from early traumas, but combine together to create a complex entanglement of the past and the present.’ They stress the importance of parent work in these cases, to support kinship carers to explore their conscious and unconscious f/phantasies about who the child is for them. This is likely to be over-determined because of the child’s and carers’ overlapping family histories. Winnicott’s (1967/1971) ‘maternal mirroring’ and Freud’s (1919) ideas around the uncanny are used to illuminate some of the complex dynamics at play in this field. I was particularly interested in an omission that the authors draw our attention to. A black child working to make sense of his identity, including his identifications around race, class and culture, enacts a split between his therapist and his teacher. The teacher is also black, but this fact is lost in the discussions around the case and so the significance of this, in relation to the therapist being white, is also slow to emerge and inform the thinking. This paper seamlessly moves between the external realities of politics, manifest in policies and attitudes, and the internal psychical realities that are powerfully impacted by those policies and attitudes. Attention is also given to how all this is mediated by the ways in which politics determine decisions around resources, including paying for support to think about how to manage contact with birth parents and other important aspects of kinship care.

In the second paper from the conference, Alison Roy explores metaphor, storytelling and the therapeutic power of woodland experiences, in work with adopted children and their adoptive parents. Roy puts forward the idea that a fiction, a version of reality that is not slavish to the detail of reality, might get closer to an emotional truth than a factual account can. She describes facilitating the power of adoptive parents to metabolise some of the trauma in their children’s stories so that their children can take the stories in without becoming overwhelmed. This is facilitated, in part, by creating peer support groups for adoptive parents, where they share and collectively digest their distinct but overlapping experiences of being adoptive parents. Finally, the parents and therapist co-author a shared story of that experience, often in the form of a poem. The importance of omission is very present in this paper too. Roy argues that while some details of an adopted child’s history might not be helpful to share, or at least not too soon, those omissions don’t have to leave gaps acting like weak links in a chain (or holes in the nest?). The careful weighing and processing of that detail that won’t be shared enables the story to keep its integrity and power, in order to contain the child in their work of identity building.

The final paper from the conference is Judith Edwards’ ‘The elusive pursuit of good enough fatherhood, and the single parent family as a modern phenomenon’. This is an exploratory piece, and the author is clear that her purpose is to ask questions more than try to answer them. She asserts the centrality of the Oedipus complex in development and challenges us to make explicit our thinking about how we use it in our work with ‘modern families’ today. She revisits clinical material from previous publications with this new purpose and draws on poetry and literature to explore many of her themes. Like Roy, she also emphasises storytelling as crucial to development, but for Edwards it is the opportunities offered by triangulation that enable a narrative that is reality-facing to emerge. Edwards states that ‘Oedipus was grappling with what Narcissus had failed to achieve: separation and a real relationship in love and hate with the other and others’. She is clear that in most single parent families, children do indeed find their way out of narcissistic ways of relating through oedipal struggles and move into healthy interdependence. However, she invites us to be curious about how this happens without the nuclear family unit that fits so neatly with that theoretical model. Despite the disclaimer that she will offer ‘no proofs’, the clinical material definitely feels to me to be presented as evidence of what can go wrong when there is no paternal function present in the family.

The remaining four short papers were originally given at the symposium our Journal organised, entitled ‘Issues around consent to publish clinical material: How do we continue to use our clinical experience to further the scientific development of our field in the digital age?’

Since joining the Journal I have been concerned by the number of authors experiencing bitter disappointment on discovering that they had not known what they needed to do in relation to gaining informed consent. Worse, by the time we were discussing it, it was often too late for them to go back and do what they needed to do retrospectively. I had also become aware of strong feeling on the subject from those who were aware of these changes. At the Journal we thought that a symposium on the subject would be helpful. Our hope was to raise awareness amongst potential authors, but also to provide a forum to explore the nuanced complexities of the topic of consent to publish. On one of the first warm sunny Friday afternoons in March, we were delighted to have almost 80 delegates attend our online event.

I had not always had such a good response when trying to engage people on this subject; but before thinking about that, I want to outline some of the complications around trying to seek consent from patients that the author is no longer working with, especially in the NHS. If we have left the Trust we were working in, that Trust will not be able to share patient contact details with an ex-employee and, even if we are still working in a Trust, if the case is closed to us, we will need to have acquired prior consent to access patient data for the purpose of seeking consent in the future. So, before the end of a piece of work that we might want to write about, we need to be seeking consent to approach families at a later date to ask them to consider giving consent. The intake paperwork at most CAMHS will ask families to tick a box saying that they are happy to be approached in the future to be asked if they are interested in participating in research. If they tick this box, we are then in a position, during the course of our work with them, to seek consent to publish clinical material. In reality, however, most papers take several years to percolate. It is, therefore, most likely that we will need to be seeking consent to take a patient’s contact details from their file to record in our personal contacts, in order to seek consent in the future.

I was aware of all this because it was the advice I’d been given as an author in the past but, on starting in this role, I wanted to clarify exactly what different Trusts’ policies required of authors. I tried to make contact with the Research and Development Directors of seven Trusts to hear about their policies in relation to publishing clinical material. I explained that I wanted to find out how we could support clinicians in their Trusts to do the groundwork for gaining consent. Only the director from my own Trust got back to me, and I have struggled to get hold of any Trust policies on the subject. It is hard to make sense of this experience and we can only speculate as to why I met such resistance, including the possibility of there simply not being the resource, and thus interest, to support individual clinicians doing informal research. I feel we all have a role to play in keeping the scientific life of our field alive, especially those in leadership roles in the NHS who might support child psychotherapy colleagues to navigate this complex terrain. I know that some authors have met resistance from within their own teams, including fellow child psychotherapists, who are concerned that authors might be putting self-interest above the needs of their patients. While self-interest is a motivating factor, we also know that the development of our theories and practice is the ultimate beneficiary. I think that this aspect of what spurs us to write is complicated because it touches upon our discipline’s unease with ambition more generally, something that may be reflected in the fact that we are underrepresented in senior roles in the NHS, given the length of our training.

In relation to the requirement that we seek informed consent, some child psychotherapists I spoke to felt angry that risk-averse publishers were strangling our discipline’s scientific development for fear of legal cases being brought. It is true that the legal landscape has changed since the Human Rights Act and developments in Data Protection Law. David Halford, a Human Rights lawyer with a long history with the ACP, spoke at the symposium on this subject. At the Journal of Child Psychotherapy, we do have to operate within the parameters of the policies and guidelines of the ACP and our publisher, Taylor and Francis, but I also want to be clear, as any author who has worked with me will know, that with each paper I am primarily led by the injunction of ‘doing no harm’ to the patient and family being written about.

I do have some sympathy with those who worry that too much is being lost. It is hard to take in how much has changed, and so rapidly, in the digital age. For the vast majority of the history of our Journal, a patient would be very unlikely to ever have found a paper about their therapy, unless their aunty was a child psychotherapist and had left a copy on the coffee table, or similar. But times have changed. Discussing this issue with my husband over dinner one day, my two children chipped in that they always google a new teacher: ‘everyone does, it’s just what you do’, they insisted. While it would take more than idle curiosity to get access to an entire paper, we know that children, young people and sometimes their parents will google us. If we have published, then the abstracts will be a couple of clicks away. If our patients think a paper might pertain to them, their curiosity will not be idle.

My position is that we have to assume that our patients might read our papers. Therefore, we must offer them an opportunity to do so before publication and seek their permission to publish the material. If we cannot ethically gain informed consent from them – that is, write in a way that would do no harm for them to read – then we must disguise not just their identity, but also the clinical phenomena, so that they would not recognise themselves in the material. The latter strategy is simple enough when offering a brief vignette. For example, if I wanted to convey something of my experience of a boy struggling to own his dependency on adults, instead of describing how he subtly gave me to understand that I should take the lid off the play-doh for him, without his having to ask directly, this could become a little girl doing the same when she could not find the end of the sellotape. However, it would be impossible to do this for an entire case study, without losing meaning and authenticity.

Either approach encroaches on all sorts of important freedoms that our profession has enjoyed in the past, and using either or both of these approaches does not free us from ethical dilemmas, as explored by the papers in this issue. We do have to grapple with these new dilemmas because we cannot, now, close Pandora’s box. We do now work in the unboundaried space of the digital world, and must adapt creatively.

My first contact with this issue was when I submitted my own qualifying paper to the JCP. I was dismayed to hear that, because it was a detailed case study, I would have to seek informed consent. It is interesting that news of these changes had not reached me in my five years of training. I explained that it would not be in my adolescent patient’s interest to hear about the transferential phenomena, some of which were luridly described in order to capture the level of disturbance. It was then explained to me that if I could not find a way to write about her treatment that she could safely read, then I could not publish. There was much that I had to omit, but in many ways the paper I wrote for her to read was a better paper. I was embarrassed to realise that sometimes it was not the content, but my tone that needed to be changed. I had been aping a rather condescending attitude, perhaps a hangover from our field’s inheritance of the paternalistic medicine model. This tone didn’t reflect my actual attitude towards my patient and the voice I eventually found was more authentic. Towards the end of our work, my patient and I spent an afternoon – more than four hours – reading through the new paper. She pointed out inaccuracies, and I corrected them. We discussed our differences of opinion and made amendments that we were both comfortable with. The process became collaborative. It was very intense, and we were both moved to recall particular points in her two-and-a-half-year treatment but at the end she gathered up the paper in her arms and said she wanted to take it home to show her dad. Sharing the paper with her became an important part of the work. But I know that this is not always how it goes. Also, I wonder if she still has a copy now. If so, how does she feel about it now that some time has passed? Does she regret having given consent at 18 years of age? Our solutions to these problems are imperfect at best, but crossing our fingers and hoping our patients don’t find our papers is not good enough.

I know these changes represent a real loss to our field – seminal papers that have been central to the development of our theories might not have been published if they were written today, or at least not in the same form. I am most worried about the difficulty of publishing about cases that involve intergenerational trauma. This is some of the most complex work we do, and we need to hear ourselves think about it, including thinking about detailed clinical material in relation to family background. We can still write those papers and present them to one another at symposia and the themes emerging can be written about for publication (something that is already happening).

There is, thus, a loss to be worked through at the level of our discipline, but this is also being felt by individual authors who grapple with questions of when it is not possible, or ethical, to seek consent for publication. In the writing workshops we are offering through the ACP, and in conversations with authors who have already submitted to the Journal without the required consents, we are learning that there is a process of mourning that needs to be worked through. The wished-for paper has to be relinquished; this can be painful work as no paper is conceived without huge investment. In time, a new paper might emerge, one less dependent on clinical material, perhaps more thematic or theoretical, or one using a fictionalised patient or patients loosely based on a composite of cases. But this paper may not be the paper the author, originally, wanted to write.

In this issue we have four papers that were presented at the symposium, each exploring different aspects of this complex and thorny issue. However, before I say a bit more about those papers, I want to offer some of the historical and legal context as presented by John Halford at the symposium. He told us: ‘the historical position was that patient information was treated as owned by health bodies and its use was constrained primarily by: common law duty of confidence; and ethical principles of confidentiality. Then came the human rights act and data protection directive (Gaskin v UK (1989). Then the European Court of Human Rights in Strasbourg recognises an individual’s right to access their care records as a component of ‘private life’.) This prompts limited statutory rights in the Access to Health Records Act 1990. But, the law then rapidly develops thanks to the Data Protection Directive, 95/46/EC, implemented in the UK as the Data Protection Act 1998, created the concepts of: data subjects’ able to exercise some control over; processing – any form of handling of; data from which they can be identified, directly or indirectly (e.g., ‘jigsaw identification’) by; ‘data controllers’ and ‘data processors’. (Halford, 2022)

All of this has culminated in the ‘Association of Child Psychotherapists (2022) Code of professional conduct and ethics’. I have selected the most relevant sections to share here:

4. Respect, trust and maintaining confidentiality …

4.6. Members must maintain confidentiality. Members have an ongoing ethical and legal duty not to disclose any information of a confidential nature which the Member has acquired during his/her professional relationship with the patient to any third party during the lifetime of the patient or thereafter, unless special circumstances apply, as discussed above, or where consent is given.

4.7. Information of a confidential nature may be disclosed with the consent of the patient or, where they are unable to take part in decision making and give such consent, a parent or other person with parental responsibility. Even when consent has been obtained, Members should carefully consider whether disclosing confidential information is appropriate and ethical, especially where the patient many not have anticipated sharing it with the Member at the time any general consent was given. In such situations it may well be appropriate to seek further consent.

… .

5.2.3. Where it has not been possible to obtain consent, the author(s) need to provide a written statement to demonstrate and provide evidence that they have given significant consideration to the process of seeking consent and the reasons why this has not been achieved.

… .

The data subject shall have the right to withdraw his or her consent at any time. The withdrawal of consent shall not affect the lawfulness of processing based on consent before its withdrawal. Prior to giving consent, the data subject shall be informed thereof. It shall be as easy to withdraw as to give consent.

When assessing whether consent is freely given, utmost account shall be taken of whether, inter alia, the performance of a contract, including the provision of a service, is conditional on consent to the processing of personal data that is not necessary for the performance of that contract.

You may notice that 5.2.3. appears to offer a ‘get-out’ clause. However, we are still bound by our duty to do no harm, and in practice this clause is what allows us to use disguise of individuals and clinical phenomena, in those cases where seeking consent is not appropriate.

We begin with Jennifer Davids’ paper, which actually came at the end of the symposium and felt, to me, like an electric current surging through our gathering on that Friday afternoon. Her writing plugged us directly into our own passions and motivations for writing, honourable and less so, and our patients’ motivations for wanting to be written about, or not. Her unflinching exploration of the issues was invigorating. She helpfully reminded us that gaining consent does not absolve us of responsibility for thinking about what that consent might mean in the context of the transference relationship. Davids offers the term ‘consent anxiety’ to capture all that gets stirred by the prospect of seeking consent. While I think this is a helpful concept, I do worry that it could be misused. It may be, as Davids suggests, that we seek consent as much to assuage our guilt, as out of respect for our patients. But, ultimately, we still need to pay our patients the respect they are due by seeking their consent. As ever, we have to attend to external and psychical realities.

Gillian Sloan Donachy opens her paper by comparing the experience of gaining ethical approval for formal research with the processes around writing a clinical paper. She points out that while we have the legal framework and codes of practice outlined above, ultimately the author is responsible for making ethical choices. There is no ethics committee to back the author up. You are on your own as the author, and this is daunting. Sloan Donachy then goes on to describe her internal deliberations around the ethics of seeking consent to write about an unusual ending to a piece of work during the pandemic. You might remember it from the Covid special issue: it described a walk in the park with her patient ‘Laura’. The author and I discussed the process around gaining informed consent to publish the original paper, and I was keen to hear about how the meeting had gone. Sloan Donachy shared how much she and her patient had gained from this unplanned contact, months after the treatment had to end. This, in turn, prompted me to ask Sloan Donachy to present that experience at the symposium. She agreed, and we acknowledged that she would need consent to do this too. They met again and ‘Laura’ gave consent and became quite interested in this process herself. It was with some amusement that we realised that in order to publish that presentation, they would have to meet again. By now, Sloan Donachy and her patient were developing a shared understanding of their journey and you will find that ‘Laura’s’ voice is in these pages, speaking for herself and making a direct contribution to our understanding.

In her paper, Lida Anagnostaki describes her and her colleague’s herculean efforts to overcome temporal, bureaucratic and physical barriers to gaining consent, which ultimately work to throw into sharp relief the importance of trust in gaining authentic consent. The powerful simplicity of this aspect of the relationship between clinician and family, and clinician and institution, is what emerges as paramount. More prosaically, this paper serves to remind us of the importance of seeking consent to take contact details whenever we think we might want to write about a case in the future.

Robin Holloway explores the anxieties he was left with having ‘successfully’ sought consent from ‘Sam’, whom he wrote a series of three papers about in this journal. ‘Sam’ was a self-professed ‘people-pleaser’ leaving Holloway feeling that he might have been exploitative in seeking consent in this context. The work with ‘Sam’ was ongoing and this transaction, consent sought and given, is likely to have impacted the work. Holloway wonders if it would have been better to only write about historical work, but then the opportunity to work with what’s stirred may be harder to create. I share Holloway’s concerns about what might be omitted if we can only write about cases where it is safe to seek consent. I agree that our discourse will be skewed by this, and we need to think creatively about how to ameliorate this effect. Holloway explores the possibilities and risks involved in using conferences and clinical symposia, so that we can hear ourselves think about those cases that it will be increasingly hard to write publicly about in detail. Holloway also ponders the ways in which the digitalisation of life is changing, not just what we do, but also what we are, in all sorts of profound ways, beyond the way we develop our ideas in psychoanalysis.

One delegate at the symposium, Emily Morgan, offers a brief response piece. Morgan shares what was stirred for her by the presentations, relating this to her own emerging wish to write for publication as a recently qualified child psychotherapist. At the Journal, we are keen to publish voices from across our discipline, including those who are relatively new to the work and I hope this piece encourages others to have a go. When deliberating about whether it would be ethical to write about one patient, she asks ‘Whose interest would this be in?’ I think this is an important question but to my mind the answer is always that we don’t write, primarily, for our patients. We write for ourselves. Some patients may benefit from being part of the telling of the story of their treatment, and our hope is that, in a more general way, contributions to the development of theory and practice might benefit all our patients of the future. However, I think it is unhelpful if we deny the fact that we do it because we want to. Only then can we really weigh-up whether that feels ethical against any potential risks.

In the Research Digest, Rachel Acheson offers an overview of some of the research into how we are being changed as we become digital humans. Attention, memory and social cognition are all found to be shaped by our online behaviours. This is no surprise, given what we know about the experience-dependent architecture of the brain. Acheson draws our attention to the fact that the latest studies are confirming something else we know about brains and minds, which is that how we experience what we do is also dependent on how we feel about ourselves and the world. As ever, she cautions, we must avoid confusing correlation with cause.

Louise Allnutt reviews a much-anticipated book edited by Jo Stubley and Linda Young, ‘Complex trauma: The Tavistock model’. This book is mainly about the work undertaken at the Trauma Unit of the Tavistock Clinic. Allnutt applauds all that is innovative and creative about the work, and the writing in this book; she makes a particular point about the way that the work, and this volume, also honour the tradition of psychoanalytic clinical thinking, and the centrality of relationships to healing, even when adaptations to psychoanalytic technique are required. Paddy Martin reviews a book by integrative child psychotherapists, both qualified and in training, from the perspective of a psychoanalytic child psychotherapist. Those of us working in the NHS may not know much about modalities beyond those usually represented in CAMHS teams. I have worked alongside, and learnt a great deal from, an integrative child psychotherapist and was embarrassed, to begin with, by how little I knew of the approach. This review allows us to peep over the garden wall, as it were, and have a glimpse of something related to our method, but different. Charlotte Ansell reviews a collection of poetry, largely about loss and mental illness. She shows us how this is both familiar terrain, in this way but also, perhaps, helpfully unfamiliar in perspective and form. By chance, it is the third time that poetry has found its way into this issue. It is said that some of the power of poetry is its parsimony – what remains unsaid in a poem. I found myself wondering about an omission in this review. The poet is referred to as ‘they’, yet we are not told anything about the poet’s gender identity. I am left curious, a little tantalised, yet also feeling that somehow I should stifle that curiosity. Am I self-censoring, because my curiosity is born of a wish to question and interrogate? Or do I shut down my curiosity for fear of breaking a new taboo? This is another way in which our world is changing, and I hope we will be able to think about that in these pages too.