By Caryn Onions
This often quoted African proverb resonates with the work done at The Mulberry Bush, a residential special school for primary aged children who have experienced early trauma and abuse. Across the school there are different types of staff working in various teams such as Group Living, Education and the Therapies and Networks Team¹, and this article will show how a multidisciplinary approach can be useful when addressing the complex needs of many of the children referred to us.
What are ‘complex needs’
Often children referred to the school have what are nowadays described as ‘complex needs’, but what does this mean? The Department of Health (2014) defines children with special educational and complex needs as;
- having a delayed developmental profile and functioning at a significant level below average for their chronological age
- not having their needs met within a mainstream setting
- presenting with significant needs which necessitate specialist interventions
Children who have witnessed domestic violence and/or experienced neglect, abuse and pre-verbal trauma are often those who go on to have complex needs. When these experiences happen whilst a child is still developing then the interventions offered need to address the deficits sustained and this is where a multidisciplinary approach and good communication can be invaluable. In order to describe how this works I am using a case study of Joanne, a nine year old girl to highlight the stages and decisions we took when planning her treatment. Whilst I am focussing on specific pieces of work which took place in the Therapies and Networks Team, her therapy was also happening daily within the therapeutic milieu of Group Living and Education. For reasons of confidentiality, I have anonymised her presentation and background but without changing the key features of our work with her.
Joanne’s mother had significant mental health problems and her father was an extremely violent man. Joanne’s early life was neglectful and chaotic. In addition she was born with a genetic disorder which means that she has some developmental delay, speech and language difficulties as well as specific learning disabilities. Surprisingly she remained with her birth family until she was seven, when the local authority obtained a Full Care Order and she was placed with a foster family. This placement broke down and the decision was made for her to come to the Mulberry Bush school aged 9. As we are a 38 week a year placement she also moved to a new foster family where she went during the holidays.
When she arrived at the school Joanne was heavily medicated, passive, compliant and spoke very little. The medications were for sleeping, for impulsivity and agitation, although at her six month review it was decided to stop all medication. It was noticeable that her speech was significantly delayed for example ‘me go Forest School’ and ‘Joe take me picture’. Staff felt warmly towards her but concerned that her ability to communicate verbally was so limited. As she got to know people she found ways of letting them know about her distress such as biting staff on the arm, or bending their fingers back, and these things seemed to be done without recognition from her that she was doing anything unpleasant to staff, or that she was even doing it. When disciplined the only way in which she was able to verbalise her feelings was to scream angrily ‘me want die!’. Her frustration was palpable. Fortunately in foundation class she eagerly joined in, which included a weekly language group and so after her twelve week assessment period we decided that helping Joanne’s communication was going to be key to helping her access all the work we do here.
Speech and Language Therapy
Assessment by Rachel, the speech and language therapist, showed that Joanne’s level of comprehension was that of a five year old and that her expressive language was even more immature. The delay in her language meant that she was missing out on much of what the staff were saying to her and she simply did not have the vocabulary to express feelings. Rachel met with Joanne weekly and helped her understand specific language structures, past, present and future tenses and linking words such as because, so, then. Adults in the house and class were able to adapt their language to support her understanding and so she was able to access more of the curriculum, and begin to get some good feelings about her ability to learn, albeit extremely slowly. As her basic language skills developed Joanne was able to more accurately start to communicate and as this happened her levels of frustration slowly started to reduce in frequency, but not necessarily in intensity when they did occur.
After six months at the school Joanne started music therapy. Having had time to settle in and start making relationships with staff and peers, and coming off her medication, it felt as if she was ‘warming up emotionally’. Staff were experiencing her frustration like a mass of feelings trying to get out, and in class she was having lots of difficulty simply staying in the room, which meant that she was being restrained more often. We also offer dramatherapy and psychotherapy, but felt that Joanne would make best use of music therapy.
Quickly through the non-verbal medium of rhythm and sound she started to show more of her internal world, although any reference to feelings either verbally or musically was unbearable, even when tears were silently rolling down her cheeks. Worryingly we could see that she had probably witnessed (violent) sexual behaviour, or certainly sexual activity which appeared controlling and frightening. After discussion in peer supervision Karl, the music therapist asked for an escort to sit outside the therapy room as Joanne wanted to take her clothes off, said she wanted sex and at times got quite out of control. It was as if being in the room with Karl was overwhelming and so the presence of a ‘third’ person was a way of safely bringing down the emotional temperature in the room. It allowed Karl to respond musically to the feelings without over stimulating Joanne, and with the nearby containing presence of the escort. During this period Karl often felt useless, powerless and worn down, and regular peer supervision was able to help him process his powerful and uncomfortable countertransference feelings. At the same time Joanne was furious that there was ‘intruder’ outside the door. However, it was not long before Joanne started to use songs in a meaningful way, she was becoming much more in touch with her feelings and enjoyed making up sad lyrics accompanied by Karl.
Meanwhile Rachel was still working with Joanne, and it felt like the speech and language input was having a positive effect on her music therapy and visa versa. Slowly, the feelings words that Joanne was learning were being incorporated into the song lyrics in therapy. Around that time Joanne renewed contact with her birth mother. She found it overwhelming and it became obvious that she was confused about her family background, why she was in foster care and at the school. Therefore the treatment team decided that Joanne could benefit from Life Story Work (LSW). The work with Rachel had started to help Joanne use and think about language that was concerned about time, cause and effect; what was in the past and what might be in the future. In addition, in music therapy she was slowly developing the ability to tolerate emotions, feelings that in the past would have been too painful to stay with, and, she was witnessing in class and group living, the way in which staff ordinarily talk to children about their feelings and behaviour i.e. cause and effect. The impact of these two therapies had enabled Joanne to reach the stage where LSW would be possible and meaningful to her. It was done jointly with Chris the senior therapeutic care worker from Joanne’s residential house and Jilly the dramatherapist. In the sessions Joanne used a soft toy (Suki) that her mother gave her and Chris used Suki to tell Joanne why she is having LSW. Used in displacement Suki became an important part of the work, representing at times Joanne, her mother and their relationship.
A developmental feel to the use of multi-disciplinary work
In this short example I hope that it is clear how the work we did with Joanne, was in response to her emotional needs but in a developmentally sensitive way. When she came to the school Joanne clearly had memories and powerful feelings but she had no language to start to put these into words, or to link them up together, which is in effect the start of making sense of the muddle. Linguistically Joanne was not able to differentiate past, present or future and consequently getting across her point of view was frustrating for her. In addition at those times Joanne was probably overwhelmed by the feelings linked to the memories. Developments in neuroscience suggests that the area of the brain which stores memories (the amygdala) and the area which processes memories (the hippocampus) are separate, but that ordinary parenting and communication during toddlerhood helps the links grow between these two areas which in turn contributes to how children make sense of the world around them (Rothschild, 2000). It is likely that when Joanne arrived at the school she had not experienced a sustained period of ‘good enough’ parenting and so when any pressure was put on her to speak, her sentences would become monosyllabic and conversations generally unsatisfactory. Also her genetic condition meant that expressive language was an area of weakness for her and this was one of the reasons for starting music therapy.
Music therapy was a way to help Joanne begin to put her feelings together for her. But more than that it was as if there was a flowing process between the speech and language therapy and music therapy, where the feelings explored and expressed with Karl were then attributed words in speech therapy with Rachel. Equally the work with Rachel would come into the music therapy room and were given musical expression with Karl. The two approaches were complementary. By creating a largely non-verbal but increasingly more coherent thread of affect, with Karl’s help in therapy, Joanne was able to revisit and play with these feelings every week. It was noticeable that her learning started to improve in class, although she could still be difficult to manage at times. Karl and Rachel would often meet together with the treatment team to review Joanne’s progress, and it was from these discussions that the suggestion of LSW arose.
Two years after Joanne started here, and with her foster placement working well, life story work (LSW) was started. The staff leading the LSW were able to use information gleaned from the speech and language therapist and the music therapist, and their important preparatory work meant that Joanne was able to engage because she had developed an ability to experience some of her difficult feelings without defending against them by shutting herself down, and she also had the basic language skills to support the thinking that is needed. Increasingly we find that two staff coworking like this offer more containment to the work, and theoretically this follows what some psychoanalytic thinkers have written about. For example Britton (1989) suggests that the ‘triangular space’ occupied by the coworkers or the ‘parental couple’ allows the child a safe place in which to reflect and see themselves. Coleman (2007) suggests that ‘Britton’s ‘third position’ has much in common with Fonagy’s (1996) concept of reflective function, the capacity to reflect on one’s own mind and the minds of others’ (p 565).
Joanne is a good example of how a child with complex needs can require a number of different and discrete but complementary pieces of work, each providing the foundations for the next piece in the therapeutic jigsaw. I do not mean that the process is linear, but that it is psychologically developmental. The makeup of the Therapies and Networks Team is multidisciplinary, where the different approaches represented have separate therapeutic roles. It means that some children will experience a variety of different interventions during their time at the school, but hopefully for the child they coalesce into something therapeutically meaningful. It also replicates aspects of a community type model of working with such children where different professionals are often under the same roof, however this type of provision is not written about in terms of residential settings.
However we also know from our experience that sometimes work with complex cases can unconsciously lead to unhelpful situations, where the processes of splitting and projection can dominate. These primitive defences are seen within individuals and organisations and that is why regular communication between staff is vital, preferably facilitated and in the presence of others who can maintain a more ‘mentalizing’ state of mind if the worker is strongly identified with the child or their pathology (Menzies Lyth 1988).
In this paper I have concentrated on the work within the Therapies and Networks Team, but in Group Living and Education, there are also multi-disciplinary inputs, for example from educational psychology. I believe that it is important when an organisation looks after the welfare of children with complex needs, that it adopts a holistic approach which includes input from a range of professionals concerned with all the developmental needs of children.
I am grateful to the members of the Therapies and Networks Team for their input and helpful comments in preparing this paper.
- The Therapies and Networks team includes three full time Family and Network Practitioners who liaise with parents, carers and other professional networks around the child, and a part-time Speech and Language Therapist; a School Nurse, a Music Therapist, a Dramatherapist and two Child and Adolescent Psychotherapists.
Britton, R. (1989). ‘The missing link: parental sexuality in the Oedipus complex’. In R. Britton, M. Feldman & E. O’Shaughnessy, The Oedipus Complex Today: Clinical Implications, ed. J. Steiner. London: Karnac Books.
Coleman, W. (2007). Symbolic conceptions: the idea of the third in Journal of Analytical Psychology 52, 565–583. London.
Department of Health (2014) Children with Special Educational and Complex Needs.
Fonagy, P. & Target, M. (1996). ‘Playing with reality: I. Theory of mind and the normal development of psychic reality’ in International Journal of Psycho-Analysis, 77, 2, 217–33.
Menzies Lyth, I. (1988). Containing anxiety in institutions. Selected essays Volume 1. Free Association Books: London.
Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: Norton.