Staying Alive: Is there a Future for Long-term Pyschotherapeutic Child care?

This paper began to take shape in my mind while I was attending the 1993 Windsor Conference of European Associations of Therapeutic Communities, which had the theme “staying alive”. It was noticeable how the papers presented from England were very much linked to economic survival, whereas the papers from the Netherlands and other parts of Europe, were more about keeping the spirit of therapeutic work alive, rather than routinised. At the time of the conference I was affected by the tragic death, in early August, of Vanessa Hick, one of our staff members, who was killed in a car accident. A very literal dimension to “staying alive” in this work. My 21 years at the Cotswold Community coincides with GAPS (Group for Advancement of Psychodynamics and Psychotherapy in Social Work) celebrating its “coming of age”. This has prompted me to think about the changes I have experienced in the work and to wonder what the future holds. This paper is a synthesis of these various strands.

I will consistently be using the term therapeutic community, which is a much abused term. David Kennard (1994) in this issue of the Journal has set out the defining characteristics of the therapeutic community concept.

In the last 21 years I have seen major changes in child care. The Cotswold Community arose out of the approved school system. The process of changing an approved school into a therapeutic community was graphically portrayed in Spare the Child by David Wills (1971)

The dismantling of the approved school system is 1969 saw the beginning of the market place in child care. For the last 21 years the Cotswold Community has had to rely on generating enough income from referrals to cover its costs. It is true to say that 15 years ago we were not worried about where the next referral was coming from. Today, although we know there are many children who need help, the rate of referral is mainly determined by the state of local authorities” finances.

The Cotswold Community has had to survive the boom in fostering. Fostering was the answer to everyone’s problems. Like many good ideas, it was “hi-jacked” by financial managers. It was the cheap solution. Of course it is better for a child to live in a family and if he needs therapy to receive this without being removed. I think it is now generally accepted that there are some children who are so emotionally damaged, as a result of abusive experiences from birth onwards, that the model of parenting plus therapy is not enough. They need therapeutic parenting. I will return to this theme at the end of this paper.

In the last few years the Cotswold Community has had to survive the denigration of residential work as a result of the scandals in Leicestershire and Staffordshire. Morale in residential work is very low. To say you are a Residential Social Worker is almost synonymous with being a “pervert” in many people’s minds. Who would want to place a child in a residential setting to be further abused? It has been difficult to get across the fact that there is such a thing as creative residential work.

For a residential unit to survive in our world today, it must be free of scandal. Or perhaps more accurately, negative media attention. Look at what has happened to New Barns. In the summer of 1992 New Barns experienced “trial by media”, which led to their closure within weeks. Peter Righton was arrested in May 1992, over allegations of possessing child pornography. He was a much respected child care consultant and trainer and was a governor of New Barns. His downfall and association with New Barns led to children being removed by parents and local authorities before it was established whether or not there was malpractice within the school. End of New Barns! If you want to take a group of children in your care to Europe for a holiday, forget it. You will be crucified in the tabloid press. If you allow a child to travel by plane, this is gross profligacy! This has created a culture of fear, of keeping one’s head below the parapet, of curling up like a hedgehog. This is hardly the climate to encourage learning. Most people learn from their mistakes. We are afraid to make mistakes, to take a risk, which is very bad for staff morale and confidence. Managing a group of disturbed children therapeutically requires a certain level of confidence in one’s own ability. It is not surprising, therefore, that most residential units are having difficulty in containing and working with the disturbance of their children.

Economic survival is another form of staying alive for the Cotswold Community and other therapeutic communities. I have already referred to the financial problems of local authorities, which prevent them from funding expensive residential placements. The current economic pressures lead to short-term thinking, i.e. how the books will balance in this financial year. There is an economic argument for placing an emotionally damaged child in a therapeutic community, but it requires a long-term view. The investment in a child’s treatment will save society money over 30 or 40 years and return a damaged individual to full citizenship. It is difficult to get this point across, though, when financial managers and politicians have become hardened to need by saying “we can’t afford it”. End of argument.

In the Charterhouse Group of therapeutic communities, (see Christopher Beedell’s booklet (Beedell, 1993) for a description of this group) of which we are a founder member, we have seen three member communities close for financial reasons – Chalvington, Peper Harow and Dartmouth House. Perhaps Dartmouth House (see Lewis (1993)) for a full description) was the least well known and yet its closure should be the most shocking. Here was a therapeutic community that worked with whole families, attempting to rectify the problems at their grass roots. This really was preventative work, saving society millions of pounds in the long run. Ah, but is there such a thing as society? If therapeutic communities are to exist in the future I feel they need to be a part of our country’s overall strategy towards its children. What standard of child care do we wish to achieve in 20 years time? Maybe what is needed is a Ministry for Children. At the moment there is a patchwork quilt of policies towards children affected by geography, political and social work dogma, finance and inter-departmental rivalry. If you live in Oldham you may get funding for a therapeutic community placement, but if you live in Liverpool, forget it.

Most local authorities set up trade barriers around themselves which have an adverse effect on therapeutic communities, e.g. a social worker in one of the shire counties, with a disturbed child that needs residential therapy, is going to find it very difficult indeed to place the child outside the county. Everything is weighted in favour of in-county provision. If the rules of the market place are to prevail then it is necessary to go the whole way and have a free-for-all in which the fittest survive. Under these conditions, at least some therapeutic communities will survive because of their cost effectiveness.

The Cotswold Community has had an unusual experience of economics, apart from the above (Whitwell, 1992). We occupy a 350 acre farm, a legacy of the approved school era. In 1973 the ownership of the Cotswold Community was transferred from the Rainer Foundation to Wiltshire County Council. Today this looks an act of sheer lunacy but you have to remember back to the early 1970s, with the newly formed Social Services Departments and with local authority finances being quite healthy, for this decision to make sense. As ill-luck would have it, a large part of our farm, contains rich deposits of gravel, the richest being under the buildings we inhabit. Over the last 15 years we have seen the pressure mounting in Wiltshire County Council to sell the gravel. We feel we are a nuisance in the way of this wish. The attitude of our proprietor is a rather grudging admission that we are doing good work and deserve to be where we are. It might have been more convenient if we had been one of the many residential establishments to close. In the world of economics the gravel business has more muscle than therapeutic child care and I am left wondering how long we can survive this pressure. The latest twist is that from April 1994 we may have to pay rent for the gravel we are sitting on, as a result of new government regulations, because of the “opportunity cost” to the County Council in allowing us to continue to do our work. “Cost effectiveness”, “opportunity cost”, “business plans” are the language of power and the power lies with accountants.

During the last two decades there have been attempts to make residential work more professional. The way forward was to move child care from a reliance on well-meaning “housemothers” who were paid merely pocket money and had a sense of vocation (an unfashionable word), to paying people a proper salary and actively encouraging staff to be non-resident. This was heralded as a breakthrough and that staff morale would soar. In my view this was not progress, quite the contrary.

Shared living with one’s clients can be a potent therapeutic force. A genuine “we” feeling can be created between grown ups and children. This is our home, we value it, we have created it. Therapeutic communities strive for this, it is the essence of a sense of community. In my view the heart went out of childrens homes when staff moved out – “your heart is where your home is”.

At the Cotswold Community we are fortunate to have inherited enough land and buildings to make living in the Community an attractive option. There are problems over issues of privacy, but the gain is considerable. Boys talk about feeling safer because there are people they know living around them.

The issue of hours at work is more controversial. I think that shift-system working in childrens homes has contributed to the feeling that the heart has gone out of the work. Children need a sense of continuity in their lives. We may feel that fairly healthy teenagers can cope with different carers, but I imagine we would agree that small children need continuity of care from a very few grown ups. What would be the effect on the mental health of toddlers if they were cared for by shifts of grown ups? Pretty disastrous! The work of Winnicott (1984) and Dockar Drysdale (1990, l1993) informs us that emotionally damaged children still have these very early needs. If we are to help them this cannot be ducked. These children need a “primary caretaker” or “psychological mother” who can be preoccupied with them as an individual and respond to their personal needs. This grown up needs to be emotionally involved with the children in his/her care and be available at key times in the day – making the transition to school, time for playing, eating together, talking and listening, bedtime. This means working long and flexible hours. I think that one of the reasons social workers turned to fostering was to find this missing commitment to children, which had left the residential work profession. Foster-parents may be amateurs but their heart is in the right place. I worry that as foster-parenting becomes more “professional” they will lose heart. Already some foster families are in fact small childrens homes, rather like the family group home, but with a lower adult to child ratio.

Therapeutic communities have by and large retained this commitment to children, as child-centred environments. They 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 (Whitwell, 1989a).

When people apply to work at the Cotswold Community they will be invited to visit and stay at the Community for several days. The danger is that they will be seduced by the pleasant environment, by the philosophy, by the niceness of the children towards them, and by their own idealised image of a community which could fill something that is missing in their lives. I have to try and get across that the most difficult thing about the work is not coping with the behaviour problems of the children, but the feelings which will surface through doing the work. People who see themselves as basically calm, caring and sensitive will be shocked by their own anger and hatred. Caring for a sexually abused child can feel hazardous. The child’s expectation and previous experience that caring has been sexualised, may resonate with the sexuality of the carer, in a complex transference and counter-transference dynamic. Damaged and abused children are experts at “pressing the buttons” in grown ups. They have had to, to survive. I say to potential workers that whatever you think you have “got over” from your past, or “worked through”, or “put behind you” it will inevitably surface as a result of doing the work. Not the least of which is facing up to the basic assumptions of your own upbringing, which you have internalised. In the residential group living context this will be challenged. If the challenge can be accepted then it can be a tremendous learning experience and enable a good deal of personal growth and self awareness for the grown up.

I have heard Barbara Dockar-Drysdale say that being involved with therapeutic child care is like having a full analysis. In the sense that I have described, this is true, but this is all the more reason for supplying the support and consultation to help the grown ups cope with this.

A very important dimension to “staying alive” is how to renew the zeal of pioneering work in therapeutic communities. If therapeutic communities rely on charismatic leaders for their existence and drive forwards, then they are doomed to wither and die with the departure of the original, founder leader.

Another form of death is for the work to become routinised. In the early days of a new therapeutic community there can be a tremendous buzz of excitement over the shared goal and vision – a strong “we” feeling. Often this is at the expense of relationships with the wider world. It is very seductive for a therapeutic community to feel, in its early days, that we are essentially good, have all the answers, if only the rest of society would catch up. From the outside, therapeutic communities can seem mysterious, inward-looking places. Hence the description by Spencer Millham of the Dartington Social Research Unit, “Therapeutic communities are places notable for the permanent sound of tinkling glass at the end of long drives”.

Perhaps in the early days of a therapeutic community it is inevitable and maybe essential to have the split between what is basically good inside and the bad outside. However, it is also important to realise this is a “quick fix” to a “we” feeling and will not be self-sustaining. To sustain this, the charismatic leader would have to deliver inspirational leadership continuously. Only the added ingredient of religion might enable this form of leadership to be long-lasting.

After something in the region of four or five years a therapeutic community will have to deal with the problem of that original “missionary zeal” beginning to fade. New staff members arrive who were not part of the first days. They will find things established – routines, norms, expectations. This may not be written down, but they will be there. This is the real test. How to maintain good staff morale as the gloss wears off and the real grimness of the work begins to surface.

To overcome this staleness the answer is not to find another charismatic leader which, again, is the easy solution – like a football club changing the manager after a few bad results. I believe the answer lies in keeping the “spirit of enquiry” alive. Not adopting the attitude that we know what needs to be done, it is just a question of finding “minions” to put it into practice.

Recognising that we are continuously trying to push back the frontier of knowledge and understanding, I believe that the Cotswold Community is helping children today that we would have failed with 20 years ago. I hope it is possible to say the same thing in 20 years time.

To keep this spirit of enquiry alive, I believe a therapeutic community needs two things:

1. External advisors – consultants – who can monitor, appraise and clinically supervise the work of the therapeutic community. They must not be seduced by the “we” feeling. They must be a constant source of irritation in their quest to help the therapeutic community stay “on task””. Residential units provide a rich breeding ground for bad practice being re-defined as good practice by this inward looking “we” group. Consultants need to see this and challenge it.
2. An organisational and management framework that supports the therapeutic task. The Cotswold Community is especially aware of the need for this having previously been a very hierarchical, centralised and punitive approved school. To convert this into a therapeutic community took much more than implanting a different philosophy. The whole management structure and organisation had to change to support the therapeutic task. The previous structure would have hindered it.

Richard Balbernie made an inspired decision, after being appointed Principal in 1967, in seeking the help of the Tavistock Institute to change the organisational structure. We have had continuous consultancy from the Tavistock. Initially it was Ken Rice until his untimely death, then Isobel Menzies-Lythe for several years and for the last decade or so, Dr. Eric Miller. They helped to change a “top-down” organisation into a “bottom-up” one. Staff working directly with the children were enabled to be much more effective. They had clearly defined responsibilities and could take decisions accordingly, including control of budgets. Adults in the previous regime presented poor role models to the boys because they were so ineffective. The organisational change reversed this.

Defining the primary task is an essential pre-requisite to organisation change, not least because what is anti-task begins to be clear and then this can be tackled.

Staying alive is important in the Winnicottian sense of “surviving” the onslaught from an emotionally disturbed child made even more potent in a group living context. The disturbed and abused child really does need to test to destruction his primary carers and it is vitally important for his sense of future hopefulness that they survive. If there is a failure to survive, this compounds the problem. Our work at the Cotswold Community is made more difficult now than before because of the number of failures already experienced in short lives. Matters of finance are likely to mean that the decision to go for residential treatment is put off to the last possible moment and, I have to say, in some cases it is left too late.

These failures fuel the sense of omnipotence in the disturbed child, a defence against the terrible reality of what has happened to him. “I can’t make someone love me, I am unloveable, but I can make them hate me and drive them away”. The death of our staff member was followed by two months of wild, aggressive behaviour from the children she looked after, as they worked through their fury at her loss. “How dare she go”. It is only now, several months later, that the fury is beginning to subside and be replaced by genuine sadness. We were not sure we could survive this.

In a very important paper “Residential Care as Therapy” (in Deprivation and Delinquency) Winnicott (1984), describes 5 essential features of therapeutic child care:

1. Reliability – children who are emotionally damaged have experienced chaotic environments which are unpredictable. The unpredictability is traumatic because it penetrates the core of the personality and creates a state of unthinkable anxiety. Under these conditions children will fail to reach emotional integration. An important part of the therapy in residential care is the reliability of the adults, which, over a period of time, can counteract the earlier experience of unpredictability.
2. Holding – both emotional and physical holding. Much of what is therapeutic in residential care is the successful holding of the disturbed child.
3. A non-moralistic attitude on the part of the carers.
4. We must not expect gratitude.
5. In the case of every child receiving therapy in a residential care setting, there must be a phase in which the child becomes a candidate for the role of scapegoat. “If only that child could be got rid of we would be alright”. This is the crucial time. Winnicott says that at such a time our job is not to cure the symptoms or to preach morality or to offer bribes. Our job is to survive. In this setting the word survive means not only that we live through it and that we manage not to get damaged, but also that we are not provoked into vindictiveness. In this sense we are trying to do something that should have been done when the child was at an early stage of development. We are bound to have some failures, and this again is something we have to survive in order to enjoy the occasional success.

Over the years I have noticed three phases in the placement of an emotionally disturbed child at the Cotswold Community. The first stage is quite short (and in some cases nonexistent) – the honeymoon period – when the child is remarkably normal: he has new hope; he doesn’t see people as they really are and the other children haven’t yet enough reasons to disillusion him. This initial period of good behaviour can be dangerous because the child is responding to his idea of what good parents would be like. The grown ups can think “he sees me as nice and trusts us”. But the fact is he isn’t seeing the grown ups as the really are at all. This ideal is bound to be shattered.

The second phase, the treaclemoon period, is the breaking down of his ideal. He starts to test the building and the people physically. He wants to know what damage he can do and how much he can do with impunity. Then, if he finds that he can be physically managed, i.e. that the place and the people in it have nothing to fear from him physically, he starts to test by subtly putting one member of the staff against another, trying to make people quarrel, trying to make people give each other away and doing all he can to get favoured himself.

When we withstand these tests the child enters the third phase, feeling relief that we have survived the testing to destruction and he becomes a more ordinary member of the group.

It is easy for the child to become a candidate for the role of scapegoat in the treaclemoon phase. If the child is expelled, another child will surely fill this role. It is important to realise that the testing out child is very often doing this on behalf of the other children in the group, who are profoundly interested in the struggle and also much relieved if the grown ups can survive.

During the last decade I have seen the traditional therapeutic community approach, characterised by permissiveness and shared responsibility achieved through a daily whole community meeting, threatened by the lack of suitable referrals. By this I mean children and young people with sufficient ego strength to benefit from large group or medium-sized group living.

Indirectly, this is another consequence of the economic situation affecting our work. Those children who can cope in a group are no longer being referred. It is the child who is of high “nuisance value” who will attract the funds for an expensive residential placement. One of the key elements of “nuisance” is an inability to be in a group, whether this be a classroom or a group care setting. These children will not respond to the community meeting being the main arena for their therapy. It is the failure to adapt to these relatively new circumstances which has, in my view, led to the demise of some therapeutic communities (Whitwell, 1989b).

The severely emotionally damaged and abused child will first of all need emotional nurturing. The breakdown in their parenting occurred at the very earliest stage in their life as a baby, when the focus was on a two person relationship, rather than the triangular relationship of the family group. It seems obvious to me that we have to go back to this two person stage to start the healing process. As emotional growth occurs that is the time to introduce the group as a key therapeutic tool.

I would like to illustrate this point by giving an example of the kind of child who is being referred to us at the moment.

This is an actual referral, although I’ve changed the identity of the people involved:

Jason is 10 ½ years old. He has a brother Simon, who is 18 months older than him. The Social Services Department have been involved with the Smith family for many years. Mr Smith had a troubled adolescence, being placed in approved schools. Mr Smith takes the leading role in the family with Mrs Smith presenting a very nervous individual who accepts her husband’s views. When Simon was born the Health Visitor had to be involved in helping them develop parenting skills, including issues of personal and house cleanliness. At four years of age Simon had unintelligible speech and very delayed developmental milestones.

Jason was very different to Simon. His poor standard of clothing led to bullying from his peer group. He had a very pathetic appearance and very low self-esteem. Jason stole food from other children – he was always hungry. Unlike Simon, Jason was capable of good academic progress. He learnt to read. Because of his abilities Jason played a parenting role regarding Simon.

When care proceedings began 2 years ago, there was some concern about the sexual behaviour of both boys, although the main issue was neglect.

Jason was placed with a foster family and reacted very positively immediately upon placement. He was thrilled with his clothes, his cleanliness and the food. After an initial honeymoon period, it became clear that Jason had profound problems and that every aspect of family life was extraordinarily difficult for him.

He ripped wallpaper from the bedroom walls, smeared faeces in the bathroom, picked his nose until it bled and smeared the blood. Jason could not settle at night appearing to have no identifiable sleep patterns. Jason had to be the centre of attention at whatever the cost and no matter how much embarrassment he could cause to his carers. Jason began to show sexual behaviour towards his foster mother. He totally confused the boundaries between warmth/closeness/affection and sexuality. Jason showed sexual interest in the younger children who either visited or lived in the family. He was sadistic, getting enjoyment from the physical pain that he inflicted on small children and the pain that he caused when trying to kill the cats. He succeeded in killing a goldfish.

At this time Jason began to describe an abusive and bizarre life at home. Jason described sexual acts involving his parents and a lodger and both children. Also scenes of sexuality and brutality directed towards animals. Simon confirmed these details.

Mr Smith is prohibited from having contact with his two sons and Mrs Smith has contact three times a year, supervised by a social worker. Jason’s foster placement ended and he was moved to a small residential unit. It is now the considered view of the network involved with Jason that he is not a child who can be placed with a family. He needs expert help with every aspect of his social, personal, emotional and intellectual development. The consultant Child Psychiatrist who assessed Jason was clear that he requires therapy as part of the total care environment. “His therapeutic needs will not be met by a once weekly visit to the therapist”.

The challenge for a therapeutic community is to be able to meet Jason’s very considerable needs within a group of equally damaged children, with finite resources. Ten to fifteen years ago Jason would have become an institutionalised child, in and out of one children’s home after another as they failed to contain him. He may well have ended up in a large, impersonal assessment centre, a relic from the approved school days. In a perverse sort of way this at least enabled the therapeutic community to have a honeymoon period, after he arrived, as he responded positively to a more caring and personal regime.

Nowadays, children like Jason will be in and out of foster families and there isn’t a word to describe the damage that is being done by this process, maybe “familyarised”. However, it means that a therapeutic community will have a much tougher job to start with because he will be experiencing order and boundaries for the first time and will test to destruction. Children like Jason initially need almost constant one-to-one attention until they become less fragmented as individuals and more integrated into the group.

Conclusion

Barbara Dockar-Drysdale, who was the Cotswold Community’s Consultant Psychotherapist from 1968-91, used Winnicott’s work as a basis for her own pioneering work in therapeutic child care. Mrs Drysdale said in 1969, “We have an enormous emotional refugee problem on our hands: thousands of emotionally starved children who are all, in the deepest sense of the word, displaced people. There is nobody beyond us to whom we can hand over this responsibility. Furthermore, a therapy of provision leading to evolvement is not available in a child guidance clinic; such treatment can only be appropriately given in a residential setting, relating as it does to the entire life of the child in need”. Twenty five years on from when this statement was made, the situation has deteriorated considerably. The work of the Cotswold Community, and other therapeutic communities, is needed now more than ever.

References