By Charles Sharpe, Evelyn Daniel & Siobain Degregorio
Date Posted: Tuesday, 22 May 2007
Good Enough Caring : using a psychodynamic approach to the care of children and young people in the care system.
In this presentation we argue that the provision of a living setting underpinned by psychodynamic theory with its emphasis on the provision of consistent nurturing can help those youngsters for whom substitute family care is not the best option. It can encourage them to begin to feel free from the threat of rejection, safe to trust the adults who are caring for them, and more confident about engaging healthily with the world they live in. We also consider the potential for unhappy outcomes when planning for the care of young people is based on expedience rather than thoughtful planning.
Introduction : a rationale for working psychodynamically with children and young people in residential settings.
The psychodynamic theories of Winnicott, Klein, Bion and Dockar Drysdale amongst others have greatly influenced the residential care of children and young people in the UK. Indeed the phrase in our title ‘ good enough caring’ borrows from Winnicott’s notion of the ‘good enough mother’ and relates it to the care of young people unable to live with their own families. Winnicott proposed that the infant’s principal caring adult, usually the mother, must provide the infant with an environment which is ‘good enough’. Winnicott’s inference was that no mother is perfect, and that neither should she be since the healthy child will grow to cope with all the ups and downs that life brings with it (Winnicott,1965). The view we express here is that the care of children who are unable to live with their parents – particularly those being looked after in the public care system – should be ‘good enough’ and though it cannot be perfect, should approximate the kind of warm consistent nurturing and attachment which most children receive from their parents.
In recent times the influence of the psychodynamic approach to residential child care in particular has waned (see for instance, Sharpe, 2000 ; & Maher 2003). This may be related to the still growing and predominant trend in social work – a trend which started in the 1980s – to view residential child care not as a preferred intervention, but as a last resort crisis response when placement in a substitute family proves impossible to arrange. We agree that for many children placement with a family will best meet their needs, but we believe this is not the case for all children who are looked after in the care system. Since the 1980s any questioning of this trend towards seeing substitute family care as the panacea for the problems of all children in care has never been adequately answered. Like Davies Jones (1981) and Stevens and Milligan (2006) we believe that the failure to answer these questions has ignored
the needs of a significant group of young people in the care system who may not be best helped by placement in a substitute family. These include all those children who have repeatedly experienced breakdowns in substitute family placements, those children whose experience of family has been so traumatic that they express themselves in one way or another as unavailable to be placed in a substitute family, and those who, along with their parents, sense that placement in a group living setting will be less threatening to the possibility of their eventual return to their own families.
We have decided at this stage not to provide a long technical account of psychodynamic theory or of what a therapeutic approach to the care of children is, but have thought it better first to explore it by reflecting on aspects of the case of two young people. By doing this we also bring out some of the problems the adoption of a psychodynamic approach in child care services brings with it.
In promoting the psychodynamic underpinning of care work with troubled youngsters we are not ignoring the possibilities of cognitive behaviourist methods but we are merely stating that in our experience many of these youngsters have problems which are too complex to provide satisfactory long-term solutions through conventional conscious verbal negotiation. They have missed out on so much in the pre-verbal stage of their lives for this to be possible.
The decline in the use of residential child care as a resource for helping troubled children and young people
Research findings in the early 1980s were critical of much of residential child care as it was then practised. A focus of these findings were the large remote residential institutions (often former approved schools) which were prevalent up to the 1970s and 80s. For different reasons, the stereotypical psychodynamic model of residential child care, the therapeutic community, tended also to be an isolated institution, aiming as it did to create a total environment where the young people and staff lived and worked together, and where the principal method of approach was to use the group as the means of therapy (Milham et al, 1975, Milham et al 1986 ). A consequence of these negative research findings was that many of the remote institutions were closed and amongst their number were the children’s homes run on psychodynamic lines.
Since the 1980s the number of children and young people placed in residential care settings has reduced significantly, as more and more children have been placed in substitute family care. The majority of children’s homes are now smaller and more locally based and these homes are the focus of this article. They might be considered the rump of what remains of a much larger residential child care service. They are situated within or close to the young people’s home community. They are accessible to the families of the young people.. They are close to their schools and the young people have ready access to their peers and the culture of the local community.
Having briefly set out a historical and current context for these homes, let’s consider the account of the care manager of a children’s home of the experience of Gerry, a young man who was placed in a children’s home – where psychodynamic theory underpinned the care provided – which was situated within Gerry’s home community.
Gerry was removed from the family home at the age of 4 because his parents were unable to care for him due to their chronic alcoholism and frequent episodes of domestic violence. He was taken into local authority care on a full care order. He had had two foster family placements before he came to our children’s home at the age of thirteen. His previous placements had broken down because his carers said that they could not cope with his violent behaviour. Gerry was a very angry young man who did not trust adults and was particularly angry at Social Services whom he blamed for taking him away from his parents.
When he arrived at our home, the staff decided that before his presenting behaviour could be addressed he needed a period of holding and containing. He could then be helped to look at the anger generated by his denial of his parents’ inability to care for him and the splitting off of his angry feelings on to those people he held responsible for his removal from his family. The recipients of these feelings were Gerry’s social worker and the staff of our children’s home.
Our task was to gain an insight into Gerry’s inner world. We had to understand how he was feeling so that we could help him to get in touch with the emotions that made him angry because he could not manage them. We also had to help him to make sense of his denial that his parents were unable to care for him because of their violence and abuse of alcohol. He could not at this time cope with the knowledge that the two people he most idealised were flawed. This part of him was stuck emotionally at the age of the 4 years old youngster who had been taken away from his home. He had been led to believe by his parents that the only reason he could not live with them was because social services had unreasonably removed him from the family home.
Gerry’s unremitting anger and violent behaviour led staff to question themselves and doubts began to surface about the efficacy of psychodynamic notions of containment and holding. At times staff themselves became dysfunctional when faced with the power of Gerry’s projection of fear, anxiety, hopelessness, lack of self-worth and above all else displaced anger. Before beginning to help Gerry to make sense of these overpowering feelings,, the staff first had to make sense of how the powerful emotions projected by Gerry were affecting them. They had to come to terms with their own anger at Gerry’s parents and also the inner anger they felt about Gerry because of his difficult behaviour. They also had to manage their feelings of helplessness because while they were aware of the main cause of Gerry’s unhappiness, they felt powerless to do anything about it. As Gerry’s acting out became more difficult to cope with, staff, sometimes consciously, sometimes unconsciously, resorted to behaviourist strategies in order to convince themselves that they were in control. It was at this time that effective management input and good supervision helped to contain and hold staff and encourage them to stay with the psychodynamic approach.
In line with current practice, our children’s home is close to the young people’s families and communities. We used the proximity of Gerry’s family to get in touch with his real feelings about his family’s inability to care for him. With the support of his keyworker, Gerry began to understand the reality of his parents’ situation. This was a painful emotional journey but it enabled Gerry to develop and test coping strategies which eventually helped him gain confidence.
A worry for staff was that the psychodynamic approach was not replicated in work with his family. Gerry had to come to terms with the failure of his family. He became able to voice that the care he received from his parents when he visited the family was not in the qualitative sense good enough for him. He became able to leave the family home when he felt unable to cope. Though it brought him sadness, he reached his own understanding of why he could not return home more permanently. Today Gerry still visits his parents but he now has sufficient control to ensure his safety. The pain and anger are still there but through confronting them with the help of the staff team, he is better able to order his inner world and respond in more socially appropriate ways. Although it originally planned to do so, the local authority has made no provision to encourage Gerry’s parents to confront their problems or to help them develop their parenting, and so it is unlikely that Gerry will return to the family home.
This case vignette was provided by Evelyn Daniel
Relationships and psychodynamic theory ; their implications for the training of residential child care staff.
The children’s home where Gerry lives is an exception. Most homes do not base their care on psychodynamic principles. Yet it is interesting that they do not, since a fundamental premise of good residential child care, indeed one which underpins the national care standards for children’s homes, is that child care must be based on the development of a stable, trusting relationship between a young person and a caring adult (NCSC 2002). A relationship of this kind is also a fundament of the psychodynamic approach. As Gerry’s case demonstrates making a relationship is a complex and time consuming process. It is a process shared by the young person and the residential worker. It requires commitment from both parties for the relationship to develop, and, if it is to be a real relationship, it needs time and space for reflection when inevitably difficulties occur. During these times the young person and the worker may need to be emotionally held by others in the children’s home. This is essential if a young person’s placement in a children’s home is to be a helpful experience. In our view what is required in terms of knowledge, skills, insight and commitment to establish and sustain such a relationship is severely underestimated. We do not believe that current residential “vocational” child care training with its emphasis on the assessment of specific skills deals with the matter of relationships sufficiently.
The psychodynamic approach to the care of young people presents difficulties for the worker who is required to ask both, what is happening for the young person in order to make this relationship work and what is happening for me, the carer in order that this relationship works? This is a difficult question for adults and, because it is not asked enough, is perhaps one reason why young people’s placements in children’s home are so often ended in an abrupt way.
There are of course many ways in which psychodynamic theory can usefully inform our work as carers in children’s homes. We list a few here.
Firstly psychodynamic work introduces us to the idea that each individual has relationships within an inner world as well as a relationship with the external world. Psychodynamic theory suggests that many of our anxieties are representations of unconscious inner conflicts which are too painful for our conscious to bear and at all times we are trying to resolve these inner conflicts in order to cope with our external environment. Wilfred Bion amongst others has argued that group living offers its individual members, through their defences, the opportunity to give expression to their inner conflicts (Bion 1961).
Secondly, these expressions, and how they are contained by the residential staff who facilitate the group, will influence the therapeutic potential of the group and will determine whether group members are or are not protected from another psychodynamic phenomenon, group projective identification, in which the group as a whole, and sometimes a sub-group (all too often the staff group), will project the fears, anxieties and other negative feelings they have about the group on to one of its members. The group’s rationalised defence of this will be that the interests of the group must come before those of an individual. Failure of the group to recognise this process for what it is – scapegoating – may lead to the exclusion of the individual from the group (Shohet, 1999).
Thirdly, Kleinian theoretical stances can help residential child carers to understand the need to be aware and to reflect upon not only the anxieties of the young person but also their own anxieties, and to understand that the primitive emotions these arouse are often based in infancy, and are stirred up by current fantasies, fears and frustration.(Klein1921). A young person may express these fantasies, fears and frustrations by acting out in a regressive way and may unconsciously displace or “transfer” these feelings which relate to previous carers – usually their parents – on to the care worker. Working psychodynamically, the residential worker looks to what lies behind these behavioural symptoms and provides a mental space where young people may safely regress to the part of their development which has been arrested by unhappy events in earlier childhood. This space, which Winnicott calls the “facilitating environment”, is where painful emotions can be held while progress is made towards a more healthy developmental stage (Winnicott1965).
Finally – although we stress this has been a far from inclusive list of psychodynamic theory and practice – Winnicott’s work on adolescence also informs the residential child care worker. He calls attention to the individual and social significance this phase has for both generations (Winnicott1971). Burgeoning young adults need to be kept safe at the same time as being allowed to take risks, as they seek to create an adult identity.
Here Melvyn Rose, the founder of the Peper Harow therapeutic community helpfully reminds us that residential care workers require the insight to recognise those parts of a young person’s development which are healthily in touch with reality, and the judgement to respond to them in such a way. Rose is also obliquely counselling the care worker against stereotyping young people by their most extreme forms of behaviour. Rose is saying that residential child care workers should be alive to those situations which demand therapy – a psychodynamic response – and to those situated in social reality, which do not (Rose 1990).
These have just a few of the ideas from the psychodynamic firmament which can illuminate and inform the task of residential child care. Yet for inexperienced and untrained staff, struggling to come to grips with complex psychodynamic concepts such as the child’s transference and resistance, the task becomes further complicated. Working psychodynamically, the carer cannot retreat to the safety of an omnipotent adult pedestal. They are asked to acknowledge and work through their own resistance and counter-transference in their relationships with young people.
This sophisticated level of self-reflection has immense implications for the recruitment and training of staff, and may in part explain why the government and those responsible for the management of caring services resist the psychodynamic approach to working with children. It can appear that they are in the thrall of the quick fix. Everything is packaged. “Packages of care” are offered to young people who are – like the rest of us – organic, individual and exceptional.
Each person grows in a unique way. Human beings should not be packaged. Yet it can seem that, the wider community, including politicians, senior care services managers, teachers, social workers and so on and so on have a need for something to be “done”, and offering a package – a short-term finite solution – becomes the dubious panacea which gratifies what we believe is a spurious need. A need engendered by a fear of being seen not to be in control.
These issues can now be considered in the light of the experiences of Mike who was placed with a project which was supporting him prepare to leave care.
Mike joined the project I managed at the age of 17 years. This was a planned move from a secure placement in a large establishment in Midlands which was on the point of closure. Mike was very institutionalised and had been told by those previously responsible for his care that he had a “personality disorder”. When he joined us Mike had no close family. Mike’s mother had died when he was 12 years old, and this was followed by the death of his grandmother when he was 15 years old. He had an aunt but she refused to see him because she thought him bizarre. Mike was a very isolated person.
What quickly became apparent to us was how angry Mike was with women. He seemed to oscillate from disdain for, to conflict with, the female staff, particularly those he thought were in positions of authority. At times he seemed apathetic towards the support he was being given and at other times he became aggressive towards women who offered him support. The staff team began to feel that it could not help Mike, and some described him as “bizarre” or “mad”. When we reflected on this at a staff meeting we realised that we were beginning to respond to him in the way of others who had previously been responsible for his care. We decided that if we contained our negative responses and did not act on them we would prevent ourselves from rejecting Mike. We might also begin to hold him emotionally. Over a period of time, Mike and his female keyworker developed a more positive relationship. This required determination from the worker, towards whom Mike projected his own feelings of abandonment and hopelessness. After six months with us Mike became able to identify that his difficulty with women centred on the physical and emotional abuse he had suffered at the hands of his mother and grandmother while he was a child. With the help of his keyworker and other staff he started to feel safe enough to explore his childhood, and to try to make sense of his pain and anger about some of the things that had happened to him as a child. Eventually Mike left the project able to make the link between his unresolved feelings about his dead mother and his anger.
Before this occurred, staff continued to find difficulty dealing with some of Mike’s communication. Where there had previously been anger seemed to be replaced by apathy. Almost a recluse to the world outside his apartment when he joined us, Mike now refused to be interested in engaging with his world inside his apartment. He became reluctant to keep it clean or tidy. He ceased to be interested in cooking for himself and began to order in junk food from food delivery outlets. He communicated to us in strange ways, such as growling and clapping his hands repeatedly. The staff’s response to his communication was to express concerns that they increasingly found Mike’s behaviour bizarre, and again they became fearful of not being able to contain Mike. They also seemed to mirror Mike’s apathy. Staff began to feel it was pointless to help him further because their efforts to do so seemed unfruitful. When discussing him at our staff weekly meetings we began to express the view that it was time for Mike to move on. We thought we had gone as far as we could with him. Only when we tried to analyse why we felt we had nothing further to offer, were we able to acknowledge that Mike’s feelings of hopelessness were being projected into us and that Mike was making us feel as hopeless as he seemed to feel. With this came a recognition that Mike’s bizarre forms of communication were those of a fearful little boy trying to frighten off a terrifying adult world, and that they were symbolic too of things he found difficult to say lest they stir up anxieties and fears he might not be able to face. By trying to understand what Mike was experiencing in this way – and this was not without its difficulties for the staff team – our need to reject Mike seemed to subside. Soon after this Mike became interested in himself and in the world outside his apartment. In our view this occurred because Mike, in further testing the boundaries of our care, had found that he could trust his keyworker’s and the staff’s commitment to caring for him. This further reinforced his feeling of being emotionally held, and enabled him to be more confident of the world he was living in. We were now able to work with his verbal communication and to help him move into a position where he could talk and respond in a way which did not mark him out as someone isolated by a lack of social awareness.
Although Mike’s demeanour seemed now to be that of someone whom we felt was more secure,,there were still problems to be faced.. Mike began to use intellectualisation to defend ideas he had begun to develop. He became very preoccupied with conspiracy theories and seemed to enjoy informing staff of his latest theory. Again it seemed to us that Mike was using unhelpful defences – though less dramatic than his previous ones – to guard against deeply held fears. Mike was given a space to express and explore his paranoid feelings without the fear of being thought “mad”, and without the fear of rejection. The secure nature of the relationships within the project, particularly with his keyworker, enabled both Mike and staff to make sense of what these feelings were and to help him move on from what seemed a paranoid defence.
Mike was making progress with this when he left us. His self- confidence had grown. He had started to attend college and he was making friendships with people of his own age. Mike was proud of his achievements and had reached a point where he could remember and acknowledge without undue anxiety, the positives and negatives of his family life. Mike accomplished this by taking one of his biggest steps while he was with us – making arrangements to read his social services files. These gave Mike many answers to questions he had about his life, and he now seemed sure enough in himself to come to terms with some aspects of his past which he had previously been unable to face. For instance he was able to see that despite her problems his mother had sought to make arrangements for his care when she realised she was becoming ill, and he was able to appreciate that his mother herself had had a difficult childhood.
Mike was with us for four years and though it was acknowledged that Mike had made great strides in coming to terms with his inner conflicts during this time there was a general recognition – including by Mike himself – that he would continue to need emotional support in order to gain confidence with all the social issues he would face when he moved into his own accommodation. Mike had been receiving support from the caring services from birth. Some of this support may not have been as good as it should have been, but Mike and those responsible for funding his four years with our project agreed that he had made progress. Yet the support from those who had emotionally contained him and facilitated him on his journey towards adulthood was cut short on his 21st birthday. Mike’s social services department said that under current legislation they could no longer fund support for him. Mike had no definable learning or physical disability, and so no service was available to him. Considering the long term investment which had been made to care for Mike since his birth, it seemed to us a tragedy that due to financial restraints, and the reluctance of the various public services to take on any responsibility for Mike’s ongoing needs (because they did not fit neatly into any one service’s domain) the opportunity for Mike to continue to grow was denied him.
This case vignette was provided by Siobain Degregorio
Mike’s fate puts us in mind of Margot Waddell’s paper “Living in Two Worlds : Psychodynamic Theory and Social Work Practice” in which she discusses the different stances adopted by social workers and psychodynamically trained workers. She argues that the psychodynamically trained worker attempts to create a mental as well as a physical place, where time is given for young people and adult carers to “be” – to reflect, to have a space where it is safe not to know, and room to process what is happening in their relationships. (Waddell, 1985) We would suggest in the current predominant social work and residential child care cultures, such an approach is not valued because it is not seen – as Waddell might say – as specifically “doing” anything and so is anathema to the “packaged” way of thinking.
Waddell also reminds us that this kind of “doing”. – always having a ready answer – is more about “servicing a system” rather than “serving a young person”. (Waddell1985) “Servicing” does not rest easily with psychodynamic child care, and may in part explain why the psychodynamic approach is not always accepted with sympathy in the current climate of child care in England. We would argue that “servicing a system” is an approach which has been imposed on social workers not solely by financial restraints but more worryingly by political and management systems which seek simple answers to complex questions, at the same time as making sure that politicians and senior managers are absolved of any responsibility should anything go wrong.
We, the adults should be able to acknowledge both intellectually and emotionally what is happening here and begin to imagine how we can provide troubled young people with the time and space they need, if they are to be enabled to grow in a healthy way. We believe a psychodynamic approach to the care of troubled young people has a valuable role to play in enabling this healthy growth.
Charles Sharpe, Child Care Consultant, Evelyn Daniel, Registered Care Manager, Eagle House Children’s Home, and Siobain Degregorio, Project Co-ordinator, First Move Leaving Care Project.
Bion, W.R. (1970) Attention and Interpretation . London. Tavistock. Cited in What Happens in Groups . R.D.Hinshelwood (1987) London. Free Association Books pp230-231.
Davies Jones, H. (1981) “Residential Care – Some recent therapeutic perspectives” in Durham and Newcastle Research Review. Vol. IX No.46. Durham. 1981 pp228
Department of Health (2002) Children’s Homes : National Minimal Standards : Children’s Homes Regulations. London. Department of Health. pp31-32
Klein, M. (1921) “The Development of a Child” in Love, Guilt and Reparation and other works. 1998 London. Vintage. pp1-53.
Maher, M. (2003) “Therapeutic Childcare and the Local Authority” in Therapeutic Communities for Children and Young People (Eds.) A.Ward, K.Kasinski, J.Pooley & A.Worthington. London. Jessica Kingsley Publishers. pp277 – 289.
Milham,S., Bullock,R., & Cherrett, P. (1975) After Grace – Teeth London Human Context Books. pp11-12.
Milham, S.,Bullock,R., Hosie,K., & Haak, M. (1986) Lost in Care Aldershot. Gower. pp1-8.
Rose, M.(1990) Healing Hurt Minds : The Peper Harrow Experience London Tavistock/Routedge. pp136-143
Shohet, R.(1999) “Whose feelings am I feeling? Using the Concept of Projective Identification” in Loving, Hating and Surviving . A.Hardwick & J.Woodhead, eds. London. Arena. 1999. pp39-54.
Sharpe, C. (2001) In Care, in Therapy ? MA Dissertation University of Sheffield.
Stevens, I and Milligan, I. (2006) Residential Child Care : collaborative practice London Sage
Waddell, M.(1985) “Living in Two Worlds : Psychodynamic Theory and Social Work Practice” in Free Associations Vol 10 Accessed on-line at http://human-nature.com/ process-press/journals.html#free
Winnicott, D.W. (1965) Maturational Processes and the Facilitating environment – Studies in Theories of Emotional Development London Tavistock Publications. p36
Winnicott, D.W. (1971) Playing and Reality London. Routledge. pp146-147.
|01 Jul 2007, Alex Russon writes|
|Is the concept of spirituality used in this work ? It is often derided, but Luke and Gerry might find a transformation in their deep-rooted condition if they could acknowledge a higher power who’s involvement in an unconscious fashion can relieve some of their burden of pressure and responsibility|
|29 Jun 2007, Heather Vincent writes|
|I have some sympathy with the psychodynamic approach which the authors espouse, but it never appears to give the neatly packaged answers that the cognitive behaviourists give and which are so attractive to the people who make decisions about how money should be spent on how looked after children should be cared for.|
|22 Jun 2007, Nancy Mohindra writes|
|This essay with its touching case studies makes me reflect on the importance of the personal qualities of the professionals who provide care for troubled young people. They have to move between friendly and firm boundaries and respectful and caring support. Are they being properly trained, listened to and supervised throughout this difficult task?|
|15 Jun 2007, Donna Hugh writes|
|Siobain Degregorio illustrates how effective her project’s therapeutic approach was for Mike and how damaging to him was the social worker’s decision,based on economics and departmental politics, to end his placement.These kinds of decisions are becoming the norm. Does every child matter ?Evelyn Daniel suggests placements are prematurely ended because child care professionals fail to ask the question ‘What issues are really affecting this child?’ Too often I think this is because the professionals know the answer is one they will find too painful to deal with.It is interesting that when we decide to be a mother, we strive to be perfect which is of course impossible. In our determination to be perfect mothers there is a danger we end up raising dysfunctional children and by the time we realise this it may already be too late.|