By Kevin Ellis
Date Posted: June 14th, 2012
Kevin Ells is a senior therapeutic care worker at the Mulberry Bush School and is a graduate of Mulberry Bush training and this article is adapted from an essay which he presented during his training. The personal details of the young person described in this article have been changed in order to protect privacy and anonymity.
A Case Study of the ‘high impact’ child at the Mulberry Bush School
The Mulberry Bush School is an independent residential special school set in the Oxfordshire countryside. It was established on its current site in 1948, by founder Barbara Dockar-Drysdale who looked after children evacuated from London during the wartime blitz. The school provides residential, therapeutic care and education for severely emotionally troubled and traumatised children aged from five to twelve years of age. Children are placed at the school for 38 weeks a year for, on average, three years. The residential aspect of the school is divided into four houses and I will concentrate my research on these houses and the various group systems that operate within them. I have worked in the residential side of the school, in Sunset house, for a number of years as a Therapeutic Care Worker (TCW) and now as a Senior Therapeutic Care Worker (STCW) and member of the Core Team (which consists of House Manager, Deputy House Manager and two STCW’s). Sunset house has, over the last few years, had a challenging child group with a number of high profile children which has contributed to a disparate staff team. This team has consisted of very resilient adults and adults who have found difficulties in both their physical and emotional resilience resulting in a particular high staff turnover in the last few years.
With this in mind at the beginning of my case study, I examined the idea of a ‘high impact child’ and how they affect the staff team and the child group, focusing not only on the practical side of the work but also the emotional aspect. I made an analysis of the relevant theoretical literature surrounding the topic in order to consider the evolution of the ‘high impact’ child. I explored ways of identifying them earlier and considered whether the way we work with these children can at times increase their impact. Due to my experience of being part of both the TCW group and the core group, I looked at the variation between the ways in which these groups think and act in regards to a ‘high impact’ child and suggest proposals for future work around ‘high impact’ children.
I looked at a number of theories that cover this area of research including Bion’s Basic assumption theory and Klein’s work on Object relations. The area I explored has elements relating to basic assumption theory which is particularly activated when task structure breaks down. For this end I talk a little around the definition of the task. Ward (2007) argues that for the work of a group care team to be effective, team members must be clear about what they should be doing and why, not just in general terms, but specifically in relation to what the outcome of their efforts is expected to be and how this then relates to the task of the team as a whole. Even if these tasks are clearly established and understood, the process will still be littered with difficulties. The team will experience these difficulties in different ways, and therefore they will manage in varying ways of effectiveness, all distracting from, and increasing the breakdown of the task.
Basic Assumptions Theory
Basic assumptions theory was devised by Wilfred Bion and is integral to the evolution of the high impact child. Bion (1961) suggested that from the basic assumption about groups there springs a number of subsidiary assumptions, some of immediate importance. The individuals in a group his their personal welfare is a matter of secondary consideration and the group comes first. The basic assumption of the group conflicts very sharply with the idea of a group meeting together to do a creative job, especially with the idea of a group meeting together to deal with the psychological difficulties of its members. Sutherland (1985) explains how Bion named these patterns ‘basic assumptions’ (ba’s). When work groups are faced with uncontrollable anxiety, they fall into one or more of three different emotional states in which basic assumption groups exist. These ba’s are ba D (dependence), ba F (fight/flight), and ba P (pairing). In the dependent group, the basic assumption is that one person is there to provide security by gratifying the group’s longings through ‘magic’. The group will seek a leader who will relieve them of all anxiety. This leader is thus invested with omnipotence and is expected to be able to solve all problems. After an initial period of relief, individuals tend to react against the assumption because of the infantile demandingness and greed it engenders.
Fight and flight appears as reactions to what the group wants to avoid, namely, the task that forced it to confront the need to develop by giving up primitive magical ideas. The group acts as if its main task is to fight or flee from a common enemy that may be found either inside or outside the group. The ineffectiveness of these solutions led at times to a different activity, for which Bion hypothesised the assumption of pairing. The development of the group is frozen by a hope of being rescued by two members who will pair off and somehow create an unborn leader. Pairing occurred repeatedly in Bion’s groups in the form of two members, irrespective of sex, getting into a discussion. Bion observed that this was listened to attentively, with no sign of the impatience from members whose own problems usually pressed them to seek the centre of attention for themselves. The group may switch between these states, sometimes very quickly, or may become stuck in one mode.
Of these basic assumption states of how a group reacts in the face of task breakdown I am particularly interested in the idea of fight/flight and have often observed a staff team come together in defence against a common enemy external to the group, often in the form of a high profile child. Kernberg (1978) offers a description of the ba states in which he describes ba fight-flight as the group united against perceived external enemies, as well as to protect the group from any in-fighting. Over the years this has been a prominent feature not only in team meetings but also group reflective spaces. Whenever the work has been particularly difficult the group will focus on the most challenging child currently in the house as core to the anxieties of individuals and the group. Kernberg continues that any opposition to the ‘ideology’ shared by the majority of the group however, cannot be tolerated and the group easily splits into sub groups which fight each other. There are a number of tendencies that the group may experience during this, a number of which have been present when a group has struggled with a ‘high impact’ child including: a need to be forcefully controlled by the leader, to experience ‘closeness’ in a shared denial of intragroup hostility, and to project aggression onto an outgroup. Therefore, there are high levels of splitting, projection, and projective identification evident within the group.
Klein’s paranoid-schizoid position
Klein (1946) suggested that in the paranoid-schizoid position anxieties of a primitive nature threaten the immature ego and lead to the mobilization of primitive defences. Sutherland (1985) explains Klein’s writings on child’s inner world of phantastic ‘objects’ (parents and parts of parents), both good and bad, its intense emotional idealizations as well as its ruthless destructiveness, and the psychotic or splitting mechanisms used from the start in coping with the associated anxieties and impulses. Steiner (1992) states how Klein believed that the individual is threatened by sources of destructiveness from within, based on the death instinct, and that these are projected into the object to create the prototype of a hostile object relationship. The infant hates, and fears the hatred of, the bad object, and a persecutory situation develops as a result. In a parallel way primitive sources of love are projected to create an example of a loving object relationship. In the paranoid-schizoid position these two types of object relationship are kept as separate as possible. This is achieved by creating a split in the object which is viewed as excessively good or extremely bad. States of persecution and idealization tend to alternate and if one is present the other is usually not far away, having been split off and projected. Together with the split in the object the ego is similarly split and a bad self is kept as separate as possible from a good self. The ego is poorly integrated over time so that there is no memory of a good object when it is absent. Klein’s paranoid-schizoid position is important to this area of study as the ‘high impact’ child has the ability to recreate the need to split objects between good and bad in the adult group causing increased friction within the group and potential conflict between these subgroups. In turn this can lead to persecutory feelings for all those involved that inevitably feed off each other. This can contribute to a challenging child developing into a ‘high impact’ child.
Relationship and Resilience
Another important and relevant aspect to discuss is resilience, both individual and group. Not only is it important to maintaining task focus but also to the role it plays in relationships. Clarke (2001) goes as far as saying that fundamental to any prevention or intervention that has a chance of success, is a strong positive relationship. Gilligan (2005) adds that theories of resilience foreground the importance of appropriate adult-child connections and inter-generational role-modelling. The building and use of relationships is an integral part of the work at the Mulberry Bush School. Smith (2009) emphasises this in the context of the type of work the school does.
“the importance of relationships and the possibilities opened up by relational approaches to practice are particularly pronounced in residential child care, which is perhaps unique among professions in placing the personal qualities of adults at the forefront of the task. While it might be desirable for other professionals, teachers and doctors, for instance, to build relationships with those they teach or treat, ultimately the teaching and treating are the primary tasks. In care settings, building appropriate relationships and using these to help children as they grow up is the primary endeavour”(Smith, 2009 pp. 119-120)
The positive use of self is not only integral to forming appropriate and effective relationships but is also seen as a major reason for behaviour change. Clarke (2001) suggests that the strength of the relationship that develops between the youth and the worker, and a relationship built upon perceived empathy, acceptance, warmth, trust and self-expression and defined by the youth as a helpful connection could account for 70% of behaviour change. While there is no denying the importance of relationships in the care profession, there is also a need to be aware of the demands this can place on an individual, and the need for this to not be about one child’s relationship with one adult but about all the relationships involved in a team of adults looking after a group of children. Meinrath and Roberts (2004) talk about how in therapeutic communities the demands around being a good staff member can take a tremendous toll as the child and the community seem to demand an incredible dedication from the staff members. These demands can increase greatly if the group is under stress and are finding it difficult to contain the chid group and manage their challenging behaviours. These stresses need to be identified, measured and managed effectively by all members of the team at all levels. Ward (2007) suggests that the worker has a responsibility to take appropriate action to make management aware of the nature and extent of the pressures under which they are working, and to propose appropriate strategies for change. Equally, he adds, the emotional pressure that many group care teams face may, if not handled well, lead to extra stress as team members struggle to cope. It is therefore not just each individual but the team as a whole which needs to monitor its work and its stress levels and to pace itself. Collins and Bruce (1984) acknowledge that the manner in which residential staff respond to and cope with work-related stress has received considerable attention, stating that…
“Some writers have identified the handling of stress as a prominent factor in determining levels of institutional success (e.g. Menzies 1970). Most stress is felt to stem from the necessity of taking risks in the residential situation and making decisions that may have profound and far-reaching consequences for the client, the worker, and even the organisation. (Walton 1978)….The impact of a very seriously damaged young person on the high expectations of residential staff in their capacity and skills to effect change can lead to considerable stress and anxiety and feelings of being deskilled and worthless (Menninger Foundation Staff 1971; Barrett and McKelvay 1980)” (Collins and Bruce, 1984)
All this has a major impact on the effectiveness of the work group. Maslach (1976) talks about how the dehumanization of the client also leads to reduced level of staff effectiveness, which further robs the client of the therapeutic skills of the staff. This dehumanization of the client arises through defence mechanisms used by the worker to counter stress. The major source of work-related stress is rooted in the context of the interpersonal relationship between residential workers and their clients. This can then have profound effects on young people as they see key figures in their lives becoming increasingly demoralised, ineffective and deskilled; these are the adults upon whom they are testing to the limit, yet at the same time upon whom they may also desperately depend. Again this contributes to a negative cycle where the defence mechanisms of the children and staff lead to the evolution of the ‘high impact’ child.
Physical aggression statistics.
With a child group that could be primed for fight as well as flight and hyper sensitive to all its surroundings, children who have suffered trauma can be prone to aggressive outbursts. The Mulberry Bush School has a number of ways of monitoring and recording levels of aggression. These include recording and grading of the levels of aggressive incidents and a record of the number of restraints initiated. Smith (2009) suggests that any aspirations an organisation might have of creative or innovative ways of working, any attempt to address emotional or educational needs, are going to flounder in the absence of a suitably controlled environment. The Mulberry Bush School, when necessary, uses physical management. The intervention strategy used is Team Teach which is a “BILD accredited training for children and adult services in positive handling strategies through a whole setting holistic approach, working with leadership and management, actively committed to reducing restraint and risk” (Team Teach Website, 2011). Smith (2009) explains how the ability and preparedness to confront the out-of-control bits of a child is central to an adult’s capacity to care for them and ultimately attach with them. We would all like to think that we could exert that control through the strength of our relationships with children or through reasoned discussion and that we can get by without restraint on the strength of personality alone. The most advanced of the techniques used at the school is the front ground recovery (FGR). The FGR is an advanced ground hold that is a complete physical restraint that almost completely restricts a child’s movement. Every half term the school collates the total number of FGR’s used to manage incidents across the school. Each incident is graded to identify its contents and if necessary the levels of the aggression. Displays of aggression and physical harm caused is graded A+, A or B, in decreasing levels of aggression.
Across the Mulberry Bush School there are a number of spaces used to handover information, discuss aspects of the task and reflect on the impact of the work. Reflection is an important aspect of all of these spaces. Cottrell (2003) discusses how reflection can help us to: gain a more in-depth and honest picture of ourselves; become more aware of our hidden motivations, our thinking styles, and of how we appear to other people; develop a better understanding of what affects our own performance and progress; develop our insight and performance; and gain more control over our own thoughts, emotions, responses and behaviour so that we are in a better position to achieve what we want to achieve. In discussing the core processes that constitute reflection Hoyrup and Elkjaer (2005) state that reflection is primarily prompted by a complex situation involving problems, ambiguity and uncertainty. In a turbulent environment these are conditions which are commonly observed and these elements and problems are evident in the day to day work of the Mulberry Bush School. Although, at times of difficulty it can be hard to maintain this level of reflection and maintain a focus of therapeutic intent, the school has a number of spaces it provides so as to maintain this reflective process.
These spaces include the Internal Case Conference (ICC), which each child will have every six months. An ICC is attended by the child’s treatment team which includes teacher, keyworker, house manager, family team worker, and therapist and is facilitated by a senior manager. An ICC will involve discussion around the work happening with that particular child and the work that needs to be done which will eventually lead to setting targets.
Tuesday clinics are also attended by the treatment team. They are facilitated by the therapist and are arranged when necessary to discuss a particular issue that may be around for that child. Each house will also have a Children’s meeting and an Agenda meeting where the team discuss varying aspects concerning the children and the work in general. There is also a weekly reflective space that alternates between a house team space operating a seminar format and a cross school peer group space. Group supervision happens fortnightly and consists of a house peer group facilitated by the house manager and Individual supervision held on a monthly basis and facilitated by an immediate superior. I intend to use anecdotal evidence from these spaces that relate to children who may be considered as high profile children and that also relate to adults difficulties and issues around the task. I will then aim to highlight how a culmination of these factors can lead to the development of a high impact child and consequently have a large impact on both the child and the staff team.
Statement of results
Looking at the collated results for the number of Front Ground Recoveries (FGR) there are a number of points that stand out. In the past twelve months there have been two children who have stood out in these figures, for the purpose of this study referred to as J and C. On one occasion J and C accounted for approximately 55% of the FGR recorded. This was not an isolated case either. On other occasions J and C accounted for over 50% of the FGR and in one half term section this figure for J and C was as high as 68% of the total number of recorded FGR’s. Obviously these figures highlight the difficulties facing the adult group in containing these children. However the behaviours they presented were not any that had not been seen from other children. The number and frequency of their incidents was not any higher than that of any previous children. The combination of the two was, although very difficult to manage, not unusual.
J was a child at Sunset house and during discussions around him, experienced adults often reminisced about children from the past who presented equally, if not greater, challenging behaviours. It appeared that the need to have a child who stands out as a bad object is an historical one.
During a reflective space one member of the team complained “…I seem to be spending all my time with J…”. This appeared to be a feeling shared by the rest of the team and became a common theme of group spaces for the next few weeks. On one occasion J accounted for 39% of the FGR. It was difficult for me to comprehend whether or not the group’s anxieties were due to J’s behaviour or vice versa. J and the group’s feelings around him dominated all our group spaces. It became an issue that I found myself becoming increasingly frustrated about. In my reflective journal I wrote.
…again it seems it is impossible for us to talk about anything or any other child without somebody going on about J. It’s becoming ridiculous. 9 children in the house everyone still thinks they are always with J. Appears that no one else sees how impossible that is. Why can’t they get over it? Shows how everyone is pre-occupied with J. Guess it’s easier to hide behind J and blame all your issues on him than do what you need to be doing. Or at least be aware of what you should be doing…
At the time, and reflecting back now, it felt like we were creating a bigger issue about J and his behaviour and that all therapeutic intent was being lost.
When totalling the number of FGR’s in each half term the numbers are fairly consistent each time. There is, however, one exception to this. In the period between September and October the numbers dropped. This was potentially due to J and C leaving. It would make sense that when two children who consistently accounted for half the number of FGR’s left the numbers would then drop. However, this reduction is a one off dip and in the following period the totals rose again to return to the previous levels. In this period the numbers are instead split between a wider range of children however, the danger is the apparent need for adults to find somebody to fill this space left by high profile children.
Turberville (2006) wrote of the excludable child and how “if only we could exclude ‘Ben’ we would be able to work with others just fine!”. It appeared that this was a concept echoed by the team and this was being played out at house level rather than as a school wide issue. In an informal meeting to plan for the evening ahead one TCW remarked “…as long as J is ok then the shift will be fine…”.
J was continually the focus of the group and they were finding it increasingly more difficult to concentrate on the task. During a particularly stressful period one TCW, during a reflective space, explained “…it’s not that I don’t want to or can’t work with J it’s just that his impact on the others is unfair…”. If things were missed for other children it would inevitably come back to being tied up with J, with one experienced TCW remarking that “…if J is not here we are able to meet the other’s needs…”.
Once J had left there appeared to be a drive from a section of the staff group to fill the void with one TCW commenting on a child’s recent challenging behaviour “…he is filling the space J left…”. Only to be informed by the manager that this child had been involved in fewer incidents than a number of other children in the house and that he was involved in less A and B incidents than a number of other children. However, parts of the staff group continued on this theme and it appeared as if there was a desire from a subgroup to create a big scary external enemy.
I am aware of the limitations of this research and its results. One year’s worth of results concentrating on aggressive incidents and physical intervention is a short time frame and restricted study. I would, in the future, look over a longer period of time and have a more in-depth look at the incidents, physical interventions and the variations in the make-up of these figures. I would also look more into adult feelings and their intervention figures in relation to this topic. I was keen to use anecdotal evidence to provide a wide range of information garnered from a wide source of meetings but also from honest adult opinions and interpretations; however this evidence is subject to memory, recording and context.
During meetings e.g. children meetings and group supervision, I propose that there is a need for an identified positive voice whose contribution in relation to that child needs to be solely positive. This role needs to be fulfilled by a strong experienced adult and would ideally be the child’s keyworker or a member of the core team. This would then balance the group’s perception of the child and increase the ability of the group to maintain a balanced perspective and resrict the development of a ‘bad object’.
In addition, I propose that the adult group, led by the core team, needs to maintain its therapeutic intent around the child and if necessary adaption of routines and structures. It is important for other children to see that adults can cope with the more challenging children. This provides the child group with the reassurance that there are adults that will be able to keep them safe in even the most difficult out of control places that they might find themselves in.
Adult meetings and reflective spaces need to be strongly facilitated, allowing the group to explore the feelings and reflect on the difficulties around a high impact child without allowing them to indulge and drive the groups fight/flight defence.
The Mulberry Bush School manages challenging behaviours on a daily basis. There are obviously a myriad of ways a child will display their feelings through their behaviour. Beneath these behaviours the staff will continually look for the communications from the child and maintain a therapeutic intent to their work. Amongst any child group there will be high profile children that can stretch the skills of the staff team and test their emotional and physical resilience. It is when a disparate staff group with a fight/flight defence and a high profile child that has not progressed effectively through the paranoid-schizoid position meet that a ‘high impact’ child evolves. This child will challenge the emotional resilience of the group and have a huge impact, not only on the adult group but also the child group and consequently, the quality of the therapeutic care that they receive will suffer.
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