Therapeutic child care : psychodynamic aspects of residential child care.

Date Posted: Saturday, 27 January 2007

© Charles Sharpe 2007

The idea that a group setting is a fertile arena for therapeutic work has many advocates. One of its most insistent proponents, S.H. Foulkes suggested that group members can modify their extreme ways of coping by learning from and articulating their underlying feelings in the “network of relationships” . Foulkes suggests that the process which achieves this is a “working towards an ever more articulate form of communication” which “is identical to the therapeutic process itself” (Foulkes,1975, p11). This optimistic view of groups offers a positive starting ideal for a young person and of course a member of staff newly arrived at a children’s home.

The adverse criticism which residential child care has received in recent decades, and the emphasis which the social work profession has placed on “normalising” the experience of troubled children by identifying an over-riding need for them to remain in a family setting – whatever their individual predicament – either in their own natural family or in a substitute family, seemed to challenge the notion that residential group care could have any therapeutic value for emotionally troubled youngsters. Research has suggested that many of the children who were placed in residential care in the 1970s, should have remained in their own families or have been placed in substitute families. ( See for instance Milham et al 1986). The decline in the numbers of children placed in residential care brought about by social policies designed to support children in their own community, was influenced by what Haydn Davies Jones refers to, with some ambivalence, as the “rediscovery of the importance of family and community in the growth of the child” as a response to ‘the Bowlby credo’. He also suggests that the subsequent numbers of children who have suffered multiple failures when placed in one substitute family after another indicates that the swing towards family placement has at times been indiscriminate. To counter this, he attempts to identify those children for whom group living may offer a helpful alternative nurturing environment. There are children he argues who, experiencing family breakdown in adolescence, are developmentally unable to take on a new family and find residential care with its opportunities for peer relationships, more congenial to their current needs. There are also those children who continually fail to respond to both family and substitute family care. They are the children who are the casualties of repeated family and foster family failure, and for whom the family has ceased to be the appropriate background for nurture. For Davies Jones these are children who are unable to respond to the intensity of relationships in families. In this latter group he includes those children, the victims of systematic physical, emotional and sexual abuse within a family setting, for whom family life has become too threatening, and indeed those children, who, notwithstanding the abuse they have experienced, retain emotional loyalties to the families from which they must nevertheless be protected. Davies Jones proposes that residential group care can provide these children with a nurturing experience which offers consistent primary caring, and what he calls the “exploiting” of the group living experience for positive therapeutic purposes (Davies Jones ,1981, p228).

David Challender places stress on the similarities of living in a family and living in a children’s home. Reflecting on his work with groups and dealing with their unconscious processes he observes that most children are brought up in a group setting, whether it be in the family, extended family, substitute family or in residential care. From the moment of birth most will experience close interaction with other human beings and will be progressively socialized by exposure to groups of other people, from family to friends and neighbours and then in playgroups and in schools. It is a lifelong process and adults rearing their own children will re-enact their own process of socialisation with the children entrusted to their care (Challender, 1999). Certainly psychoanalytic theory from Freud’s Oedipal propositions, through to Bowlby’s attachment theory emphasised the child’s primary need for attachment to another and socialisation (Freud, 1931; Bowlby, 1976).

Young people in children’s homes are for the most part victims of a failure of this primary caring and socialisation process and life in a children’s home attempts to rekindle the process by providing a special primary carer – sometimes called a key worker –  and by providing positive group experiences (Davies Jones, 1981).

Many kinds of group experiences take place in a children’s home. In some children’s homes therapeutic treatment groups, facilitated and led by specifically qualified therapists, are set up to achieve specific therapeutic goals, but in the ebb and flow of life in a children’s home there are always other groups forming, operating and breaking up. These are not specifically therapeutic groups, and though they can be formal as well as informal in nature, they are widely acknowledged as having therapeutic possibilities (Aveline and Dryden 1988). These groupings represent the greater part of group life in a children’s home, and in a large measure define the context of all the group work in the vast majority of children’s homes. Since most of those who work in children’s home are not formally qualified to facilitate “group therapy” or indeed individual therapy, these non-specific therapeutic groups are a principal focus of this paper. In addition to staff meetings, most children’s homes have regular formal meetings in which both children and staff participate. These have the function of organising living arrangements and responsibilities, reviewing recent events, sharing information and dealing with consequences of failed expectations and boundary breaking. In short, these meetings serve the purpose of achieving the institutional aims. There are also other formal meetings such as eating together at meal times, and, as in some children’s homes, attending class in the school room. There are groups formed in which only a small number of children and staff participate which may also involve others from outside the children’s home such as parents and social workers. Less formal sub- groups are continually assembling, dispersing and re-establishing for impromptu activity such as discussion or recreation.

It is this complex of groups which meets the child who enters a children’s home. Melvyn Rose, the founder of the Peper Harow Community offers the reminder that the basic anxiety each child resident in a children’s home carries with him is triggered by the normal process that exists within any group. People leave, people arrive, and for all groups new problems are continuously being thrown up (Rose, 1990). However the child psychotherapist  Barbara Dockar Drysdale suggests that children placed in children’s homes have not developed the repertoire of psychic responses that normal life experiences require. For them new arrivals are experienced as though they are actually displacing siblings, while familiar residents and staff leaving throw them back into their past traumas of loss and rejection. Consequently their reactions to these processes can be extreme (Dockar Drysdale, 1961). Nevertheless, as Rose points out, the milieu of a children’s homes is created in order to allow this to occur (Rose, 1990).

If one of the primary tasks of staff in a children’s home is to sustain the meaning and purpose of what seems such a potentially volatile group, can psychodynamic theory offer insight into how this might be achieved ? Freud, who did not differentiate between individual and group psychology, held that being a member of a group is a consequence of the group we are born into, or, have an attraction to or, that it represents an unconscious desire to be like the leader of the group (Freud, 1921). The Scottish psychoanalyst Ronald Fairbairn, in considering the development of social groups, suggests that such groups are sustained by libido ( a sexual and a life energy) and that the cohesion of a group is dependent on the extent to which libido is bound within the group, and the extent to which the group can exclude aggression from relationships within the group. For Fairbairn the roots of the social disintegration of a group lie in aggression (Fairbairn, 1935). Children resident in a children’s home are not living in their natural family setting and are rarely placed there because they are attracted by, or identify with the notion of living there. They are placed in a group care setting because their parenting figures have failed them, and consequently other adults have decided that they will stay there. These are pained, anxious, fearful, and at times, angry children. As Fairbairn suggests, these are elements which may not be conducive to a cohesive group and yet, as has been indicated, a primary function of a children’s home is to use the group setting to facilitate a child’s development from a state of emotionally painful anomie towards a position of identification with the home and the parenting it provides.

Rose observes that while these overtly threatening elements can create a chaotic regressed infantile group, such a group is regarded as normal in a children’s home. Coping with this abnormal “normality” is the very essence of the therapeutic group task. Nevertheless, he suggests, even by those standards life becomes intolerably difficult, and that necessary solutions have to be developed, by clarifying so far unexpressed relationships, and attempting to begin to resolve the problems which arise from them (Rose, 1990).

Of course developing solutions in such an apparently chaotic environment is a problem for incoming staff, while a problem for established staff is to communicate a sense of purpose to new children as well as new staff. A great deal has been written about the efforts of those charged with developing a therapeutic group care setting to create an internal culture which facilitates personal growth and change among the members of such a group (see for instance : Balbirnie, 1966 and Bettelheim, 1974). For the inexperienced residential child care worker, this helpfully speaks in practical language grounded in psychotherapeutic theory. Yet however well prepared a newcomer to residential group work with children may be at a conscious and rational level, the actual experience of the variance between the culture of the therapeutic group care setting and that of the wider community, is less easy to prepare for and to contain emotionally. Rose points out that a group of human beings rarely, and then only fleetingly, achieves perfection. The community of staff and residents in a children’s home is also subject to the rivalries which split families. He argues that the survival of a children’s home depends, just as the survival of a family would, on how it manages itself in the wider social context; how it responds to departures, separations, failures, betrayals, and human inadequacy (Rose 1990).

It is not therefore surprising that for staff in children’s homes, the acting out behaviour which these issues engender in the resident group, seems to expend an inordinate amount of time and emotional energy. It can feel as if the children’s demands are endless and progress can seem non-existent. It may appear to be a child’s fervent wish to frustrate those who are most committed to his care, and to hurt those who persist in sustaining a caring relationship with him. In this state of conflict staff may experience what  the psychotherapist Robin Shohet, in expanding upon the Kleinian concept, describes as “group projective identification” which may lead to “scapegoating”. In attempting to discard its frightening bad or unacceptable parts the staff group puts them into someone else(Shohet, 1999). Inevitably the question arises, “Can we sacrifice the needs of all the other children for the sake of one?” Clearly a negative response represents a failure of the holding environment.

If, as related literature suggests, the challenge for those striving to create and provide all that the children’s home should offer, is to create for children who have been emotionally deprived, a group living culture which they experience as emotionally dynamic and in which individual growth is encouraged to the extent that when on leaving the children’s home a young person is substantially able to cope with the vicissitudes of family or adult life, how will those entrusted to carry out the group care task be prepared and sustained in carrying it out?

As noted, Freud claimed that people are drawn into, and remain in groups because of emotional ties between members and that one of the principal processes effecting such an attraction is identification – the process by which a person seeks to be like his parents. Freud suggested that an individual introjects a preferred person or the qualities they like in that person, while at the same time projecting some of the bad or painful qualities of themselves on to others. Accordingly when each member of a group internalises the same qualities as the leader, they can identify with each other (Freud, 1921). Isobel Menzies Lyth, discussing the development of the self in children residing in institutions, suggests that it is through introjective identification that the development of the self takes place. In language which has a faint resonance of Social Learning Theory she contends that healthy development depends on the availability of appropriate models of individuals, relationships and situations for such identifications. While acknowledging that these models may be available to the children in the adults who care for them, importantly she stresses that the individual adult’s relationship with the children, together with the adults’ relationships with each other and the ambience of the setting for care, are all also models for introjective identification. She recognizes too that a child’s healthy development may require the management of the child’s identification with inappropriate models, for example other children within the institution. She argues that children in the group living setting of an institution are likely to find the most significant models for identification within the institution as a whole, and in its sub-systems and in the individual children and staff. Like Bettelheim (1974), she sees this process as the basis of the concept of the institution as a therapeutic milieu whose primary task may be described as providing conditions for healthy development and providing therapy for emotionally damaged children. It follows then that all the child’s experiences in the institution contribute positively or negatively to the child’s development, not only through education, individual or group therapy or child care, but also by the more general features of the institution. Such an aggregate she argues, points to a need to take a wide view of an institution in assessing its effectiveness in carrying out its primary task. This assessment would include the whole way the institution functioned, its management structure, including its division into sub-systems and how these related to each other, the nature of authority and how that is operated, the social defence system built into the institution, and its culture and traditions. These then have to be considered in the context of how far they facilitate the provision of healthy models for identification, or alternatively inhibit the provision of such models. Although it is possible to regard the whole institution as the model, Menzies Lyth suggests that for the child the impact of the institution is in large measure mediated through its staff who are the individual models for identification. While individual staff have their own personalities with their differing strengths and weaknesses within the institution, she maintains that the extent to which individual staff are able to deploy their personalities, their different qualities, their strengths and weaknesses within the group care setting will depend on characteristics inherent in the institution. She maintains that due attention should therefore be given to the maximizing of the opportunities available for staff to deploy their capacities, and for it to be seen that children respond to them (Menzies Lyth, 1985).

For Dockar Drysdale this symbiosis between the children and the staff can only be achieved by the staff having an awareness of the dynamics of the inner world of each of the children (Dockar Drysdale 1959). A problem posed for the worker in a children’s home is how this awareness of the individual’s inner world can be separated out in a group setting.

Ronald Hinshelwood in his search to find out what happens in groups begins to explore this. He suggests that the group is “concerned with the transportation of stressful experiences between people”. This clause encapsulates life in a children’s home. He suggests that it represents a dynamic which can be understood as a “container” in the sense that projective identification, “the transportation of stressful experiences” towards another person is the phantasy that a part of one’s self has been removed to another who now contains it. Acknowledging this notion as Kleinian at source, but further elaborated by Winnicott and Bion he describes the construct as similar to the baby whose mental state is contained by the mother (Hinshelwood, 1987, p230).

Ganzarain elaborates upon this with a suggestion that the group can be experienced by its individual members as an entity representative of the mother and so in the group setting the individual may regress to an infantile interaction with the group, and since projective identification will be at work within the group this will also lead to the re-enactment of mother-infant interactions. Ganzarain suggests that as “internal objects are projected on to other individuals in the group in an attempt to force them into assuming desired roles, they are also projected on to the group entity” (Ganzarain, 1992 p205). As an embellishment of this concept it is also possible to view the group as a transitional object performing the holding function during the process of separation and individuation, in the sense that a transitional object is utilised to assist in passing from the state of being merged with the mother to being separate from the mother (Winnicott, 1988).

W.R. Bion developed a construct of the group performing a holding or containing function by describing the relationship between the container, (the group) and its contents, (the group members). He isolates three kinds of relationships. Firstly he describes a situation akin to an institution where there is a rigidly held social order, where the group as the container crushes its contents. Secondly he describes another akin to a revolutionary situation where an idea or a person destroys the established social order, and finally he describes a relationship in which the container and contents manage to accommodate each other so both are able to develop and grow(Bion, 1970). Hinshelwood suggests that while the first two relationships represent non-therapeutic containing, the third represents flexible therapeutic containing, in the same way as a mother, though pained by her child’s acute distress, holds the child’s feelings until her understanding is projected into the child so that he may grow as she does in the process(Hinshelwood, 1987).

Taking direction from Freud, Bion also proposed that the behaviour of an individual in a group is a critical indicator of the individual’s inner world. The inner world has dynamic processes, particularly fragmentation and integration. For Bion the defence mechanisms which individuals have, the denial of internal and external reality, splitting, projection and idealisation are evident in group situations (Bion, 1961). Robert M. Young appears to go further than this, by suggesting explanations of both group and social phenomena can be governed by the same principles which govern individual phenomena (Young, 1994).

It is possible to extrapolate from Bion’s work on groups certain principles which would inform the tension that exists for workers when they weigh up what is happening for the individual and what is happening for the group. Firstly Bion infers that the psychology of the individual is in essence group psychology. Each member’s behaviour influences the behaviour of others in the group. Secondly, if there is potential for a group to be released therapeutically, it is essential to recognise that the oscillating emotions of the group and its members have an impact on the apparently conscious expectations of each of its members (Bion, 1961). Young recounting his experience in groups describes this process through what appears to have been painful personal experience. Remarking on the interaction and the amalgamation of the inner world of the individual and the inner world of the group, he infers that it is helpful for those who work in groups to be aware of the constant potential of a group to oscillate spontaneously from being a task oriented group to being a group “in the thrall of psychotic basic assumptions” (Young, 1994, p91). For all who work in children’s homes this will resonate powerfully.

Bion observed how a group could swing from “work group mode” which, if sustained over a period of time offers the possibility of growth and development, to “group mentality” in which a connection is made to unacknowledged aspects – basic assumptions – of the individual group members. In this mode, time, growth, and task performance are lost. According to Bion each of the different basic assumptions which he specifies, throws up leaders who tend to be “elected” out of the operation of primitive group processes (Bion, 1961). Menzies Lyth saw these elections as arising as a consequence of a process of splitting off the unacknowledged facets of other individuals, and projecting them into the leader or an idea, agreement being reached rapidly and collusively as to which member or idea it should be. The individual who is “elected” is likely to find the natural characteristics which suited her for the role exaggerated by the involuntary acquisition of similar aspects by other members, until her own identity is almost obliterated (Menzies Lyth, 1989). This is a cautionary tale for workers caught up in a group and its processes, who find themselves engulfed in a situation where their role as both an externally appointed facilitator, and parental figure, with all the formal responsibilities these carry, may become confused by the role assigned them, or indeed to others, by the “group mentality”.
In a study which may to an extent be adumbrated by the behaviourist or cognitive quality of requiring an observable, and preferably positive result, Duffy and McCarthy, working with young women in a residential setting believe that the group processes described by Bion, if managed judiciously during the routine and ritual meetings of the group can encourage individual emotional growth. It is their view that development is possible in a situation where two conflicting messages, those of confrontation and support, are simultaneously experienced. When this occurs individuals become able to take more responsibility for their actions and sustain changes subsequent to the group. Though conceding that the group may be influenced by both adolescent energy and adolescent alertness, they argue if the staff group leader and the staff can contain the changing culture of the group by feeding it back immediately, so the group culture switches from “that of the streets, to the domestic, to the judicial court, much as in the same way as Bion describes his adult group switching from a theocracy to a playgroup” (Duffy & McCarthy, 1998 p154 ; Bion 1961). For Duffy and McCarthy if these energies are held within the group by competent facilitation, then positive changes of atmosphere were evident in the overall life of the group (Duffy & McCarthy 1998).

Just as there is a concern for residential child care workers – untrained and ill-informed as they often are about group dynamics, and forced all too frequently to fall back on what Ward describes as “intuition” that “is not enough” – carrying out the role of facilitator in both formal and informal group settings, in the same way there is also concern for the manager of the home carrying out her group leadership role. Ward notes the intense pressures for the manager to stay on task at the same time as staying in touch with the individual and collective anxieties within the home(Ward 1998). Rose observes that though the pronounced reliance of children and staff on one charismatic leader has been viewed with concern in recent times, children and staff invest a great deal of significance in the person who is the head of the home. This is a phenomenon which is widely evidenced and of course would not have surprised Freud ! Rose however suggests that if the leader is too overtly significant then the staff may begin to feel less mature than before they came to the children’s home. Nonetheless, given that the leader can hold to the kind of position Duffy and McCarthy describe, for Rose it becomes important that the leader should not underestimate or retreat from the dynamic significance of her leadership role in the overall group, or the young people will cease to be held to the therapeutic task. At the same time he maintains the necessity for continual dialogue between the head and staff about the centrality of the leader’s role, for if this ceases, then individual members of staff begin to act out feelings in the ways that seem to imitate the young people, and where there is conflict between the staff and the leader, anxiety is fuelled among the children, excited by their early experience of parents in conflict (Rose, 1990, p52-3). Going further Menzies Lyth  stresses that by entrusting responsibility to non-management staff, they are enabled to provide positive ego, superego and defensive models which are fundamentally important to emotionally disturbed children whose personality development is immature and damaged. The ego and superego strength of staff having been fostered by the delegation of management tasks allows them the opportunity to demonstrate it to the children effectively, who in turn, she argues, become more able to be involved in control over their own circumstances and are given less opportunity to consider themselves as helpless and victims of uncontrollable circumstances. Pertinently she suggests insecure staff will make insecure children feel even more insecure, more anxious, and inevitably, less predictable. In a regime which manages delegation of tasks efficiently, it is, she continues, possible to achieve consistency and to avoid presenting children with conflicting and confusing messages (Menzies Lyth, 1989).

In summary, if child care workers are able to acknowledge the therapeutic possibilities of the group – a group consisting of workers as well as children – and to recognize the complexity of the group’s dynamic, as indicated by the theoretical stances which have been explored, so it becomes possible for them to understand how the group’s behaviour mirrors the unexpressed feelings of its individual members. A worker’s recognition of this process might enable her to be closer in touch with each of the young people’s specific emotional needs and so help her become clearer about them.

A residential child care worker operates as a group worker in a special way. Her work cannot merely be seen as a timetabled task in a busy week, although some of it may take that form. It is much more a continuous involvement with a living group to which the worker and her colleagues belong, and which gives them opportunities to intervene for caring therapeutic purposes. Since workers are so much part of the children’s life they are experiencing the conflict which can envelop the group, and though at times life in a children’s home seems to be an endless round of quarrel and crisis, as a consideration of some psychoanalytic theory has shown, these conflicts often represent crucial issues in child development. Veiled in the projective petty bickering, shouting and acting out within the group, may be poignant questions concerning separation anxiety, identity, sexuality, social inability and other emotive issues. From this it can be seen that the worker’s task is to use these conflicts constructively, and in a paradoxical sense to welcome them because used skilfully they can be a means of helping children acquire fresh learning, better ways of coping and some self-awareness.

As has been seen there are dangers as well as opportunities in working with groups and it demands insight and skill from the worker. The dynamic of the group encompasses processes that can hurt and damage individuals within the group if they are not husbanded towards help and care.

Charles Sharpe, 2001

© and Charles Sharpe



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