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Therapeutic Communities and Therapeutic Fostering: Similarities and Differences: My Journey.

John Whitwell Managing Director, Integrated Services Programme and formerly of the Cotswold Community.

Paper presented at the conference, “Using high quality residential care to meet the real needs of children: from theory to practice”, on Monday 4th October 2010 at the Northern School of Child & Adolescent Psychotherapy, Leeds.

A brief description of my journey

After leaving University in 1969 with a degree in Economics and Sociology I got a job in a brand new Probation Hostel in Old Windsor.  I was there for 3 years and was fortunate enough to be sent on a course at the Tavistock, which introduced me to psychodynamic thinking and concepts.

I moved to the Cotswold Community in 1972 with my wife and 2 children and remained there until 1999.  The Community was situated on a 350 acre farm and inherited the buildings of what had previously been an Approved School, so all the staff lived on site in what in effect became a therapeutic village.  I did the Advanced Course in Residential Child Care at Bristol University under the tutorship of Chris Beedell, and later trained as a Group Analytic Psychotherapist in preparation for taking over the Principalship from Richard Balbernie in 1985.  I regard the period 1972 – 1985 as an apprenticeship served, learning the trade of managing and leading an organisation which aimed to meet the needs of seriously emotionally disturbed and damaged young people.

I joined ISP in 1999 as the Chief Executive, and later the Managing Director, to test out whether this trade could be applied in a different type of organisation.  ISP was looking for someone who could take over from the Founder Director.  There had previously been a couple of attempts at this already, both of which misfired.

When I look over my career I can’t avoid noticing that I have twice taken over from charismatic founder leaders.  Both handovers were hugely challenging and even though planned there seemed to be an unconscious element of not wanting their baby to be in the hands of another (not unlike the dynamics of fostering).  Anyway, that’s another story for another time.

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Another similarity for both organisations was the presence of what Eric Miller called a “sustaining myth”, ie, a story of how the organisation was born in the context of insurmountable odds, which made the founders seem even more heroic.

In the case of the Cotswold Community, the “sustaining myth” was the way a war hero came in and tackled the punitive regime of the Approved School, and with a small band of fellow  “warriors” created a therapeutic community.  This was written up in David Wills’ book, “Spare the Child”.

In ISP’s case the “sustaining myth” was how a small group of foster carers (who had been part of Nancy Hazel’s pilot project for difficult-to-place teenagers, the Kent Family Placement Service) started the first independent fostering agency in 1987.  An important part of the myth was the kitchen table of one of the carers, around which this group met to form the new organisation.

Organisational dynamics fascinate me but this is not the main subject of this paper.

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Children Coming into Care

What will be their common experience?  Maggie Fagan wrote a short paper, “Who cares?  The emotional needs of young children”, in the book, “Loss, Identity, Relationships: Care Stories”, which describes briefly what babies and toddlers need and what happens if they don’t receive it.

How you are cared for in the first few weeks and months of life affects the way you come to care about yourself for the rest of your life. It is not the only factor that influences how each and every one of us develops, but it is always significant.

A baby cries for his mother, for food and warmth. At first the baby isn’t sure if mum will come, but she does, and when this is repeated an endless number of times, the baby builds up a picture in his mind of a mother who feeds him, looks after him, tries to understand him and keep him warm both physically and emotionally. The baby gradually builds up a resilient picture in his mind that if mum isn’t here, she is just over there [the opposite of feeling abandoned].

When mother can be confidently expected to come back soon, waiting isn’t too difficult and the baby has a reassuring experience that mum can be depended upon and that painful feelings can be managed without becoming absolutely overwhelming.

But what happens if the baby’s experience is not like this but is full of adverse experiences, with need and vulnerabilities remaining unmet? Instead of a helpful and soothing mum, the baby encounters somebody out of touch with her infant’s state of mind or even worse, responds to the baby in a way that is abusive or neglectful.

The answer then to “who cares?” is “no one” or “my mum but only some of the time” – and the children struggle to have a consistent and reliable view of their place in the family – and in the wider world.

Maggie Fagan

How children respond when their needs haven’t been met.

  • By not caring and withdrawing
    Another possible answer to “who cares?” might be “well I don’t” as the child switches off his desire for contact and tries to avoid all feelings of disappointment, loss, anger or frustration by not caring.
  • By pushing boundaries
    Some of these children feel compelled to test the boundaries, as if driven by a conviction that all good things come to an end and it is better to meet that end sooner rather than later. [This can be as extreme as testing boundaries to destruction.]
  • By demanding total attention and possession
    To feel uncared for is a devastating experience of loss. For many young children, one way of avoiding these feelings of loss, is to imagine that one can have everything.
  • By pushing away intimacy
    When attention does come it can sometimes provoke terrible feelings of resentment at just how deprived the child was in the first place. Then an experience of being close to another, which perhaps the child actually wanted, feels too much and the child pushes the adult away because of the original pain of being so deprived.
  • By becoming aggressive
    Often children who don’t have anyone to love, and who are not securely loved by their caregiver, find it more difficult than other children to control their aggressive feelings.
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Therapeutic child care, whether in the institution or a family, aims to address the underlying emotional disturbance.  How does it differ from child care in general?

Barbara Dockar Drysdale, in her paper, “The difference between child care and therapeutic management”, wrote:

The differences between child care and therapeutic involvement are best seen by comparing the two kinds of work within the framework of everyday life.  For example, child care workers know a lot about food and just what children need to keep them well, therapeutic workers……, while they are aiming to provide a balanced diet, are tuned into the emotional needs of the child where food is under consideration.

For example, a child who has a problem with sharing, linked to an anxiety as to whether there will be enough, could have a negative reaction to a cake being divided into slices.  A whole, small cake may be a more complete, emotionally satisfying experience for this child.

Winnicott described a caring environment which paid particular attention to the emotional needs of children as a “facilitating environment”.  Its purpose being to support the child’s “maturational processes”.  What are the components of this facilitating environment?

I’m involved in training ISP foster carers in therapeutic child care and I use a gardening analogy.  It’s interesting that it also features within this conference. (One section of the conference programme was, “Key ingredients: From the Warehouse towards the Greenhouse)

I invite carers to imagine themselves as gardeners of the emotions, helping undernourished, battered and sickly plants to grow.  Somewhere in Winnicott’s writings he refers to the growth potential that is in a bulb, rather than the gardener.  The gardener creates the right conditions for the bulb to grow and flower.  That is our role as carers.  Some plants need a more sheltered environment initially, as with some children, hence the greenhouse analogy.  It is probably true to say that an excellent therapeutic community can provide more shelter than a family.  Foster carers are in the community and inevitably children will be more exposed to the elements, so to speak.

Let’s unpick some of the strands of this facilitating environment, this sheltered garden.

  • Carers who are committed, interested, involved and genuinely care.
    This can’t be taken for granted.  Carers can burn out in both a residential and family setting.  They can become hardened to distress.  It can become just a job.  Emotional involvement is essential.  Perhaps there is more of a sense of vocation in a family committing to this difficult work.

    Continuity of care is important for unintegrated children and I think this is more achievable in a foster family.

  • A nurturing environment
    Carers who can feel comfortable with regression, show emotional warmth and emotional involvement, which creates emotional holding. This includes respecting children’s transitional objects.

    Initially I had to lie on the floor next to Katie’s bed, holding her hand until she fell asleep as she was so frightened and confused.  During this time everything was done with sensitivity, not rushed, looking all the time for indicators of the effect of the trauma she had experienced in her life so far.  Gaining Katie’s trust, setting in place boundaries and structure at practical levels that she could understand, were fundamental at that point.
    (an ISP foster carer)

  • Regular only-child time with carer
    This is an injection of a grownup’s undivided attention. It is the opposite of responding to attention-seeking behaviour, which needs to be reframed and seen as attention-needing.

    Bob (aged 13) demanded constant attention, and he would get it, if he was not satisfied, by tapping on the doors and windows, messing the dogs about, and having to be told constantly to leave them alone.  He was like this from the moment he opened his eyes in the morning until he went to bed at night.  He liked me to go into his room when he went to bed at night to read to him or tell him imaginary stories.  I showed him a few relaxation techniques to help him settle down and go to sleep and he liked to have his hair stroked.  This in no way felt anything other than the need of a little boy who wanted a reassuring touch.  He seemed like a much younger boy than his 13 years and he liked the one-to-one attention. Bob has grown out of this need and will say good night to us in the sitting room before he goes to bed.
    (an ISP carer)

  • Carers who can be firm as well as nurturing
    Boundary/limit setting. This is about setting boundaries and limits which is a tough ask in a family.  Children placed in a family have more daily transitions to navigate, eg, going to and from school.  The child is living in the community so external influences will be more difficult to manage.

    I went through several changes with my relationship with Andrew.  I had to be strong and consistent with him and always carry out my promises.  I felt I needed to gain trust and a little respect.  We decided to call me the boss in the family unit to show Andrew that women can be respected.  I felt that he had seen women being poorly treated with no control.  I also gave a lot of nurturing to Andrew and we shared books and did a lot of fun activities.  I gave him lots of praise when he was good and we shared a sense of humour.
    (an ISP foster carer)

  • Carers who are trying to understand the meaning of behaviour – development of psychodynamic thinking.  Love by itself is not enough
    Many carers will intuitively do the right thing without knowing why.  Unless carers receive training to help make sense of behaviours which are symptoms of the underlying emotional disturbance (panic rages, disruption, no guilt, splitting), they will burn out.  At ISP foster carers receive support in the form of consultations with our team of therapists.

    We have not worked before with a child who has suffered multiple abuse.  Our development has intertwined with Michael’s and we have seen him grow into a loving, happy boy.  Our ability as foster carers has expanded as we have sought guidance from other professionals, such as therapists and psychiatrists.  In return we have felt valued for our work and ideas.  We have learned the need to be flexible in our approach to dealing with difficult situations and the fact that it is sometimes necessary to take a step back and reflect on the past to see clearly the progress in development.
    (an ISP foster carer)

  • Carers who can make the child feel safe and protected from harm and trauma
    This is about the formation of trust which is closely linked to the formation of an attachment to the carer.   You probably know the story during the blitz of London, how a small child, who was physically in an unsafe environment, but nevertheless felt secure in the arms of his mother.  This contrasted with many children who were evacuated to ensure their “safety” but who felt terribly insecure because they were separated from their main attachment figure.

When we have all the elements in place for this “facilitating environment”, this garden of the emotions, we can expect to see growth in the following areas:

  • the child begins to trust a reliable grown-up
  • allows him/herself to be dependent.  Will drop some of the “I don’t need anybody” defences

Jack (aged 4½) appeared to be a happy little boy, with a constant smile on his face.  However, it was like a smile through gritted teeth.  He was a very lively little boy who always wanted to be busy and he was very independent.  He could bath himself, dress himself, clean his teeth, put his shoes and coat on without help.  This showed us that he had always to look after himself as nobody was really there for him.  We had to gradually take over his care and let him know that we were here to look after him.  He didn’t need to be grown up as he was just a little boy.  He had a need to be looked after as he allowed us to help him with things like cleaning his teeth, washing his face and hands, cutting up his food for him and general things like that.
(an ISP foster carer)

  • begins to feel sad as some of previous losses can be faced up to and mourned.  Moving away from the defences of delinquent excitement
  • the child’s true self feels safe enough to emerge.  This might show itself in the form of a younger child’s need for regression, transitional object, seeking emotional warmth
  • a real interest in food emerges – conversion of delinquent excitement into oral greed (Dockar-Drysdale)

Thomas was suspicious of any food that didn’t come out of a frozen packet or tin.  We will never forget the look of sheer horror and disgust when he first saw us feed our baby organic meat and vegetables.  Whenever we were out he would panic saying, ‘When will we eat?’, even if we’d just had a cooked breakfast and he knew we were only out for two hours. We responded by putting small portions of new (previously untried) food on Thomas’ plate and assuring him that he didn’t have to eat it, but he might be missing out on something he really loved if he didn’t try it.  Whenever we went out we would make sure we always took a variety of snacks and drinks and always said we’ve got cash if we need anything, so that he could enjoy the outing, feeling secure and cared for.
(an ISP foster carer)

  • the child starts to play – fantasy play – symbolic communication

When I could see Thomas wanted to play but felt he couldn’t, I’d start playing with Josh and then say, ‘Thomas, could you do me a favour and help Josh build the lego.  I need to get on with the dinner’, thus giving Thomas the opportunity/permission to play.  His lack of early opportunities to play really showed when my son got a sandpit for his second birthday.  Our 2 year old didn’t get a look-in.  Thomas was in there for nearly a week solid, making tunnels, castles, and all sorts of amazing structures.  There are many similar examples where his regression was necessary to fill in the blanks of missed development and opportunity.
(an ISP foster carer)

  • able to use complete experiences – experiences with a beginning, middle and end

Emotionally deprived children’s memory bank is full of incomplete, interrupted experiences so this is the expectation.  Good complete experiences can feel too rich (like giving a starving person a 10 course meal) and therefore rejected or spoilt.  This can be very difficult for a family to understand and cope with.  It might be a family holiday or trip out that is spoilt.

  • a growing ability to communicate feelings

Helping carers to help the child move along the continuum from, at one end, hitting people, through to breaking things, through to verbal abuse, through to putting feelings into words, at the other end of the continuum.

What is “therapeutic fostering”?

Therapeutic fostering is not ordinary family life plus a dose of one-to-one therapy, in the same way that a therapeutic community is not just ordinary, good child care plus a dash of therapy. Therapeutic fostering requires the whole network around the child to form an emotionally containing framework.  This process is well described by Systemic Family Therapist, John Hills, in the following way:-

This model [does] not aim to set up a therapeutic community but rather create a therapeutic network operating for the child within a community-based, non-institutional setting.  It [seeks] to maximise the possibilities for positive change by harnessing the transformative potential of both collaborative practice and the fostering relationship…….

A significant minority of the children placed with ISP have no access, or restricted access, to their extended families and networks.  The reasons for this vary though significant factors are their challenging behaviour, the serious risk of harm to the children and the failure of care plans – notably adoption breakdown.  In reality, the child’s natural kinship system, as with a therapeutic community, comes to be one of wholly professional surrogacy and the child becomes reliant on the “social interest” (Adler’s term) of professional staff.

At ISP the dramatis personae of this professional kinship network (with varying degrees of visibility for the child) are: the child’s foster care family; their respite care family; the advisory carer (the experienced carer mentoring their carer); their classroom teacher, their special needs assistant; the educational psychologist; their individual therapist or systemic therapist; and the agency social worker.

All members of this professional network function as surrogate attachment figures and mediate the daily life of the child in a very immediate way.  Where there is estrangement from the natural family, the child becomes dependent on this professional system and its ability to “hold the child in mind”, think together, problem solve and help the child make difficult decisions and choices……

[I would go further and say that this is also true for many children who are not estranged from the birth family.]

Surrogate families are required to be skilled family systemic practitioners bringing to their daily lives an awareness of family process – attending to the structure, boundaries and communication patterns in order to manage the changes the arrival of the looked after child brings to their system.  The child’s temperament, character, and attachment maps will impinge on their own children as well as on the parenting partnership……..

For the child the risk is equivalent to the survivor of the Titanic’s maiden voyage being invited to another sea journey on her sister ship!  Thus a sustained process of dialogue, interactional working out and emotional learning are required to facilitate the fit.  At times in the family crucible this process is fraught and conflicted, producing patterns tending to chaos and breakdown.  A child whose strategic repertoire is geared to anticipating and surviving loss, failure and rejection will recreate the familiarity of this drama with the unsuspecting carers…….

Through social interest, resilience, ingenuity, persistence and an understanding of attachment, foster families may observe the transformative change from a dissonant self to a more consonant self – and they are themselves changed through the encounter.

John Hills
“Holding the looked after child through reflecting dialogue”
Context 78 April 2005 (AFT Publishing).

The full version of this paper is available here, on ISP’s website >.

A fostering agency practicing “therapeutic fostering” has to have everyone signed up to and understanding the primary task in the same way as a therapeutic community, eg, drivers have to understand the importance and difficulties that emotionally disturbed children have with transitions.

When I arrived at ISP the primary task of drivers seemed to be to keep the cars clean as all food and drink was banned.  Emotionally unintegrated children often need food and drink to help them cope with transitions/journeys.  The guidance was changed and drivers now have training and supervision.

Facilitating contact between the child and his birth family is difficult and complex work.  Contact supervisors need training and support to understand the complexity of the dynamics they will be working with. (Mrs Dockar Drysdale’s paper on emotionally damaged parents.)

Making Relationships

Making relationships is surely one of the most important elements in human development.  Institutional child care has, on the whole, failed pretty miserably in helping young people develop this capacity.

Therapeutic child care (whether in a therapeutic community or foster family) must encourage the capacity to make relationships.  We know that the capacity to develop lasting and meaningful relationships develop in accordance with the opportunity of the child, especially the very young child, to form secure attachments.  The good ordinary family gives an excellent opportunity where the young child is likely to form a focal, intense attachment.  He forms other important, although less intense, attachments with others in the family and gradually his attachment circle extends, as he grows older.  Moreover, the people in his circle of attachment also have attachments to each other which are important to him for identification.  He not only loves his mother as he experiences her, but identifies with his father loving his mother and extends his concept of the male loving the female (and vice versa).  For the most part, institutions have dismally failed to replicate that pattern.  This was certainly true of larger institutions in which all staff indiscriminately cared for all children, and prevented child/adult attachment.

Foster families, it seems to me, are in a better position to encourage the making of relationships.  One of the reasons I decided to leave the Cotswold Community was the pressure to reduce the working week for staff which I thought would undermine the emotionally unintegrated child’s need for continuity of care.  These children haven’t achieved sufficient ego strength to cope with their main attachment figures being absent for the majority of the week.  I see foster families as being able to offer this continuity.

Conclusion

In 1989 I wrote:

Therapeutic Communities have the advantage over fostering in being able to train, support, manage, supervise and provide consultancy to staff to help make sense of the very disturbed behaviour of damaged and abused children.  There can be a terrible sense of isolation in a family when trying to cope with these difficulties.  Ordinary family events, like mealtimes and bedtimes, can be disrupted in a dramatic way by the narcissistic rage of an abused child.  Carers need support and guidance in the face of this onslaught and therapeutic communities have a tradition of providing this for their workers.

As you can imagine, I would write this somewhat differently now.  ISP foster carers receive a high level of training, support, supervision and our team of therapists act as consultants to the carers, as well as seeing individual children for therapy.  I think foster families can feel isolated, but so can a residential team when, for example, the children won’t go to bed and are rampaging round the building.

ISP overcomes this isolation through the support network for each family, plus a 24 hour, 7 days a week on-call system available for all families.  Therapeutic foster families work together as a team so that, for example, mealtimes and bedtimes are recognised as sources of great pleasure, contentment and nurturing as well as triggers for flashbacks of previous abuse and consequent acting-out behaviour

Group living, when there is a positive therapeutic culture in the group, can be a tremendous force for good.  A group with a significant number of “culture carriers” can help a newcomer to see the advantages of accepting what is on offer.  However, the opposite can also occur.  A negative anti-group culture can occur, when the collective illness outweighs the collective health, and drag members downwards in a vicious spiral of negativity.  During my eleven years at ISP I have seen young people successfully placed with a family following an expulsion from a group living environment.

A well-run therapeutic community, with a coherent psychodynamic approach (and there are very few of these in existence now) is a very emotionally containing environment.  In my view, foster families can get close to this providing they have all the pieces in place that I have tried to describe.

References

B E Dockar Drysdale – “Emotionally Deprived Parents, 1969”
(available to read here on the site >)

Pat Hancock, Sally Simmons & John Whitwell – “The Importance of Food in Relation to the Treatment of Deprived and Disturbed Children in Care”
(available to read here on the site >)

Nancy Hazel – Extract 1, “The Original Phase: the Kent model and developments up to the mid-80s”
(available to read here on the site >)

David Wills – “Spare the Child” (1971) Harmondsworth: Penguin Books