The Residential Treatment of Unintegrated Children: Implications for Therapeutic Communities

The International Journal of Therapeutic Communities, vol. 10(2), 1989

There are clear differences among the therapeutic communities for children and young people. It should be possible to assess the needs of children more accurately and to match these to the therapeutic approaches of the different communities. In this connection I wish in this paper to convey the importance of Winnicott’s concept of “integration”.

My proposition is that unintegrated children need special management i.e. a more containing environment, and it is the integrated child who needs a democratic type of therapeutic community. I will illustrate the treatment needs of the unintegrated with a more detailed account of emotionally “frozen” children.

The therapeutic approach of the Cotswold Community is based on the work of Donald Winnicott, Barbara Dockar-Drysdale and Richard Balbernie. Winnicott had direct experience of residential communities while he was involved with hostels for evacuated children in Oxford. Dockar-Drysdale started the Mulberry Bush School 40 years ago and in 1967 she joined Balbernie, as a consultant, in the conversion of an Approved School into a therapeutic community – the Cotswold Community.

Integration as an Achievement

Winnicott asserts that in the early stages of the developing human individual it is necessary to think of integration as an achievement. It is, therefore, necessary to think of an unintegrated state out of which integration takes place.

Before integration the individual is unorganised, a mere collection of sensory-motor phenomena, collected by the holding environment. After integration, the individual IS, that is to say, the infant human being has achieved unit status, can feel I AM. The individual has now a limiting membrane so that what is not – he or not – she is repudiated and is external. The he or the she has now an inside, and here can be collected memories of experiences, and can be built up the infinitely complex structure that belongs to the human being. It does not matter if this development happens in a moment or gradually over a long period of time; the fact is that there is a before and an after and the process deserves a name to itself.

No doubt the instinctual experiences contribute richly to the integration process, but there also exists all the time the good enough environment, someone holding the infant and adapting well enough to changing needs. Someone cannot function except through the sort of love that is appropriate at this stage, love that carries a capacity for identification with the infant and a feeling that the adaptation to need is worthwhile. We say that the mother is devoted to her infant, temporarily but truly she likes to be preoccupied in this way, until the need for her wanes. This I AM moment is a raw moment; the new individual feels infinitely exposed. Only if someone has her arms around the infant at this time can the I AM moment be endured – or rather, perhaps – risked.

Before integration there is a state in which the individual only exists for those who observe. For this infant the external world is not differentiated, nor is there an inner or personal world or an inner reality. After integration, the infant begins to have a self. In the period before integration there is an area between the mother and the infant that is both mother and infant. If all goes well, this very gradually splits into two elements, the part that the infant eventually repudiates and the part that the infant eventually claims. We can expect relics of this intermediate area to persist, and to be seen later in the infant’s first affectionately held possession, a “transitional object”. The object is one of the bridges between the individual psyche and external reality.

As the self becomes established and the individual becomes able to incorporate and hold memories of environmental care, and therefore to be capable of self-care, so integration becomes a more reliable state. Thus dependence becomes lessened. Once integration has become a maintained state, it makes sense to use the word “disintegration”, rather than unintegration, as the negative of integration.

Integration and the attainment of unit status bring great new development in its wake. Integration means responsibility. Accompanied as it is by awareness and by the collection of memories, and by the bringing of the past, present and future into a relationship, it almost means the beginning of human psychology claims Winnicott.

Emotional Deprivation

During the phase of the baby’s absolute dependence on the mother or mother substitute, basic trust is established through the sense of being “held”. This, for the baby, has two aspects:

1. Being kept safe from unpredictable and therefore traumatic events that interrupt “going on being”, and
2. Being cared for: the baby’s physiological needs being met through an empathic understanding of what he is feeling like.

Mrs Dockar-Drysdale’s work at the Mulberry Bush and Cotswold Community focussed on children who had not achieved basic trust, where the holding environment, in the above sense, was not good enough. In her paper The Provision of Primary Experience in a Therapeutic School, she writes:

“In the course of normal development, the separating out of mother and baby is a long and gradual process; at the completion of which the baby exists for the first time as a separate being, an integrated individual, absolutely dependent on the mother but no longer emotionally part of her. If integration of the personality is to take place (usually by the end of the first year of life) the evolution of this process must not be interrupted. Interruption of this process, which mothers and babies work through together in their own time and in their own way, is in my view the trauma which lies at the root of the various types of causes of emotional deprivation referred to us … The point at which traumatic interruption has taken place determines the nature of the survival mechanism used by the child; the primitive nature of these mechanisms does not prevent them from being used in a highly complex manner.” (1968)

The emotionally deprived child is preneurotic, unable to experience guilt or anxiety, and functioning at various primitive stages of development. For a neurotic chid there may have been inadequate continuity between the intra-uterine and post-natal phases, but nevertheless he has enough protective and protected environment to make it possible for him to build a separate personality structure, capable of integrating good and bad experiences and responding to them rather than being helplessly buffeted. He is thus able, having reached integration because of good enough infant care, to embark on the long voyage of secondary experience.

The absence of the early natural and instinctive reciprocity between mother and baby leads to emotional damage, which we attempt to correct in planned environmental therapy in residential treatment. We work on the boundary between well-being and non-being and it is our task to provide that sense of containment and of secure boundaries and perimeters, and of the interface between inside and outside, of which the individual has been deprived in earliest formative experience.

Incompatibility of the Treatment Needs of Unintegrated and Integrated Children

Before embarking on a more detailed discussion of the therapy for unintegrated children, we must note that experience shows it is impossible to treat unintegrated and integrated children in the same residential therapy group. With integrated, neurotic children we can assume the presence of an identity, a functioning ego, a capacity for concern and anxiety. None of these assumptions holds good when we come to consider those who have not achieved the establishment of identity.

Winnicott put it as follows:

“In a group or residential community where personal integration can be taken for granted, the children bring their own integrating forces with them. In a group where the children have not achieved personal integration, i.e. are unintegrated, cover has to be provided, like clothes for a naked child and like the personal human holding of an infant newly born. In a group where there is a mixture of integrated and unintegrated children, the illnesses of the children will dominate, and the more normal children, who could be contributing to the group work, cannot be given the opportunity, since cover must be provided all the time and everywhere.”

Mrs Drysdale explains that the fundamental incompatibility between integrated and unintegrated children living together occurs because those children who have not been able to establish a more or less functioning self are deeply threatened when confronted by functioning in others. They react to such a confrontation by a primitive defence, which can be termed disruption, e.g. if an unintegrated child comes into a group of integrated children who are playing an organised game, he will feel so threatened by the functioning children, he will at once attempt to disrupt or disintegrate, the group. The integrated children in the functioning group will become so anxious in the face of such repeated disruption that they will lose their capacity to function and feel very resentful towards the disruptive children and towards the staff for failing to prevent this.

The unintegrated children cannot tolerate functioning in others unless it is directed towards provision for themselves: the integrated children cannot stand constant disruption of their functioning as individuals or in groups.

Another aspect of the incompatibility of integrated and unintegrated children is the incidence of panic amongst the unintegrated ones. Anyone can panic for brief periods every so often, but unintegrated children panic constantly when emotionally they are in a gap within themselves. Panic can appear as rage, fright or despair: it can result in violent acting out or total immobilisation; explosion or implosion. The therapeutic treatment of panic involves holding, or containtment, and very intensive care from a deeply involved therapist. Nothing is more difficult than to treat panic in the middle of a normally functioning group – at a mealtime, or in a class, or playgroup, for example.

The existence and extent of panic and disruption can give some indication of whether or not a child has achieved personal integration.

Unintegrated children need special management, especially at mealtimes, bedtimes, the early mornings and play times. Bedtimes always present difficulties to unintegrated children, producing frequent panics, acting-out and disruptive activity, unless their needs are being met. Such children need to be cared for in a very special way e.g. they need personal hot-water bottles, special “tucking-in” and highly personal communication with the therapist worker concerned when they are in bed. They may need a special kind of drink or sweet, their own cup and so on. The following is an example of this kind of personal communication:

When I went to visit Nigel (a 14 year old) he was cuddling Winnie – a pink teddy. He told me that Winnie was lonely and needed a family. He wanted me to make a Mrs Winnie and a little baby Winnie. Nigel then said he needed something special to eat. I agreed, but said the idea had to be his – that I couldn’t just guess. He thought a while and then started talking about a home when he was 5, and he had found a baby bird in the street. The bird had been attacked by a cat, but was still alive. Nigel took it home and tried to feed it. The bird refused all food and died. “It was probably the wrong food”, he said. He lay very pensive for a few minutes, then said that when he was 5 he loved Farley’s Rusks and hot milk. He talked for a while about how his mother used to give him the rusks and then asked if this could be his special food that I give him at night and I agreed. I left, having put Winnie on his special cushion and said goodnight.

This contrasts with the needs of integrated children who require reliable adult figures on to whom they can transfer the unresolved conflicts concerning their parents. They require ways in which they can make positive use of aggression, they require opportunity for “open” communication and the conversion of delinquent acting-out into communication. They require encouragement and opportunity to accept responsibility as individuals in a group, and here “shared responsibility” is meaningful and important. They require to be helped to accept reparation and helped to reach such reparation when they do damage to others and they require help in modifying a harsh and basically rejecting super-ego. They require opportunity for achievement in adventurous activity and in skills, and to value their capacity to function.

The Residential Treatment of Unintegrated Children

At the Cotswold Community we provide a distinct environment for the unintegrated and integrated children.

Below a certain level of ego functioning a highly specialised setting is needed within which one may treat the disturbed child. This is a setting in which therapeutic management is conscious, specific and definite, and consequently provides a high level of additional security.

If a person has not developed the capacity to distinguish properly what is “inside” himself and what is “outside” and to control the boundary between them, then he needs to be somewhere where there are clearly defined and simple boundaries in the external environment. The less developed are the former, then the stronger, more clearly defined and less complex must be the latter. In the residential community everyone must be clear who is inside and outside what, otherwise chaos and breakdown ensue. In working with disturbed people there has always to be clear definition with regard to individuals, groups and systems and their boundaries.

In some respects the therapy is the “order” of the community and the ego-functioning and behaviour of the staff. The milieu, the whole management structure must reinforce and support this; if contradicted it will re-enact and echo earliest environmental failure and breakdowns.

Unintegrated children need: (i) a basic sense of well-being, which they have never had; (ii) an order that they can identify with and internalise; (iii) the symbolic equivalent, reliably provided, of missed earliest experience. This external order or holding environment is for the unintegrated very like the earliest mother and baby experience.

In his paper Group Influences and the Maladjusted Child, Winnicott explained that where you have a collection of relatively unintegrated people they can be given covering, and a group may be formed. Here the group work does not come from the individuals but from the “covering”. The individuals go through three stages:

1. They are glad to be covered and they gain confidence;
2. They begin to exploit the situation, becoming dependent and regressing to unintegration;
3. They begin, independently of each other, to achieve some integration and at such times they use the cover offered by the group, which they need because of their expectation of persecution. Great strain is placed on the cover mechanisms. Some of these individuals do achieve personal integration and so become ready to be moved to the other type of group in which the individuals themselves provide the group work. Others cannot be cured by cover-therapy alone, and they continue to need to be managed in an institution without identifying with it.

The least integrated (or most unintegrated) children have been described by Barbara Dockar Drysdale as emotionally “frozen”. This is one of the most primitive forms of survival mechanism caused by the fracturing of the primary bonding process with the mother at a very early stage.

A typical “frozen” child in a therapeutic institution presents a curiously contradictory picture. He has charm, he is apparently extremely friendly, and seems to make good contacts very quickly. He is neither shy nor anxious in an interview, and in his everyday existence he is usually healthy, clean, tidy and orderly. He is frequently generous and kind to younger children, especially one particular child, whom he protects against all attacks. In astonishing contrast he may become suddenly savagely hostile, especially towards a grown-up with whom he has been friendly. He will fly into sudden panic rages for no apparent reason, in which he smashes and destroys anything in his vicinity. He is a disturbing element in class – a storm centre – and frequently has acute learning difficulties. Sometimes he seems to build a high wall between himself and other people, which is impossible to scale or break through. He steals, lies and destroys relentlessly and without the slightest indication of remorse. He is always either cruel or wildly over-indulgent to animals, which appear afraid of him. It is repeatedly reported that he is improving and hopes are raised; it is claimed that he is making a relationship at last, but each time disaster follows until finally he becomes intolerable. The longer the period of supposed improvement, the more drastic is the breakdown; experience teaches us to think in terms of lull and storm, rather than maturation and regression or recovery and deterioration.

The “frozen” child is, of necessity, delinquent; he may easily become a “delinquent hero” who gives permission to the other members of the group to break in, steal or destroy. His own lack of remorse, the fact that he can do these things without emotional discomfort, has the most disastrous effect in a group.

We know that he cannot risk being left short of satisfaction for an instant, because the moment that the level of his pleasure drops, pain will flow in. Having withdrawn from frustration he must therefore use any means in his power to maintain the pleasure level, since postponement of satisfaction cannot be risked. It follows, naturally, that such means will inevitably tend to be delinquent. If, however, the larder door should be locked, grown-ups’ pockets empty, or windows securely latched, then crises will follow, and the second type of merger will take place; in the effort to keep himself from self-destruction he will attempt to destroy his environment, which is felt to be an extension of himself.

How does he ignore inevitable consequences? Firstly, he has achieved what Fritz Redl termed “reality blindness”. He does not merely deny that he has done some delinquent or aggressive act, he does not know that he has done it. Secondly, he has no concept of time. There can be no past to regret, and no future to consider. He lives in the present.

It is very difficult to treat frozen children. From a state where nothing is felt and no-one is important, you begin to see some internal conflict and dependence on grown-ups, with evidence of depression and anxiety, which to us are real signs that emotional recovery is occurring.

There seems to be two stages to the depressed period. The first is general, and applies to every sphere of the child’s existence. He will often become ill, he will be apathetic in every situation and will sit with tears running down his cheeks. He tends to retire to bed; he sits quietly in class, but with no sign of intellectual interest; he altogether presents a tragic picture. It is a kind of “unfocussed depression”. The second part of the depression is different; it is focussed on the person with whom the child is now making an attachment. When this second stage of depression has been reached it is not any longer apparent in every field, the child begins to make educational progress and becomes quite worried and anxious in various aspects of his life. There is, however, the deepest possible attachment to the grown up of his choice, and in the absence of this person for any length of time the most desperate anxiety is expressed. Disapproval from the special grown-up is intolerable, and there is evidence of a reaching out towards dependence. Providing that this second stage can be reached, there is little likelihood of reversal, as far as we can tell. The earliest stage is by no means so established and the child may revert to the previous delinquent pattern.

The first stage of depression could well be a “state of mourning”, for the loss of the unity of mother and baby, traumatically broken off, i.e. the realisation that this is something that cannot be regained. The second state of depression seems to represent the establishment of a relationship with the therapist. It is important that the frozen child should go through the first part of the depression, because at some point or other during this he faces the fact that he has lost the unity for ever, and that this cannot be regained. During the latter part of the treatment when such a child has become an anxious, sad person, deeply dependent and infantile, one sees him now and then attempting to use the old mechanism, which now no longer functions because he has ceased to be “reality blind”.

At no point is one justified in being merely permissive with a “frozen” child; one must be controlling, disapproving but not rejecting, approving but not seduced into serving as an extension of the child. At first the behaviour pattern is most carefully observed and reported, until constant repetition of the pattern has made it familiar to the therapist. Next, interruption is introduced; this involves breaking into a behaviour pattern at a critical point in order to make the child aware of what he has done, is doing, and plans to do. A next stage is reached when the first signs of a pattern can be recognised. Each child has a sort of signature tune, which becomes familiar. Interruption now takes place at so early a stage that we are justified in speaking of anticipation.

When interruption or anticipation is used correctly, acute disturbance is felt by the child, and he needs a great deal of support and reassurance. He will do everything in his power to close the gap that has been made in his defences. His response to early interruption is panic and rage, often with actual suicidal threats. If, however, the gap can be kept open by steady interruption and anticipation used in the context of his everyday life, then the next stage may be reached; he returns as it were to the chaos beyond which he has had to isolate himself. Here we meet the first unfocussed depression which affects every field of the child’s life; during it he re-experiences the loss of the unity and faces the fact that his cannot be restored.

It is at this stage that a kind of bond can be achieved with the therapist, the child becoming utterly baby like, dependent and trusting, completely vulnerable and helpless. It is from this point that he can slowly become loving and loved as a complete person.

Let me briefly describe Stephen, who is an intense boy like a live, fizzing electric wire or time-bomb, who creates a sense of immense danger around him. When he is beside himself he can be dangerously violent in quite impulsive acts such as simply picking up a knife and going for anyone in the vicinity. This only occurs when he is suddenly totally swamped by panic. He was adopted in the second year of his life. There had been four foster placement removals, all before he was fourteen months old. The adoptive parents were elderly, but deeply caring, deeply religious people. The father is a Scot and is a fairly morally rigid person but again with immense social concern. The mother is also a loving and caring person, more flexibly firm, but one who has been deeply and irrevocably damaged by her experience with this fundamentally damaged child. On meeting him at an Assessment Centre he simply glowered and would say nothing. He had for months refused to speak to his adoptive parents or even to see them when they brought him presents. The staff at the Assessment Centre found it necessary from time to time, when he would act out violently to put him in a cell. He has moved, following a two year period of therapeutic management and provision at the Community from being emotionally “frozen” to the border line of integration. He remains dangerous and exhausting but is undoubtedly on the way to recovery. At times his level of insight is staggering. This stage of the work is particularly difficult with him for the moment of integration is terrifying. It means for the first time being responsible for things inside oneself.

What relevance has the Concept of Integration for Therapeutic Communities?

The unintegrated person has few inner controls; he is unable to contain excitement and impulse and is completely dependent for well-being on an external “ego-function”. As he is not a container, he has to be contained by an adult who provides the necessary boundary and boundary control system between inside and outside until a degree of differentiation begins to evolve. Choice, self-government, shared responsibility are irrelevant concepts here at this level.

The principles of the traditional therapeutic community are based on treatment in the area of integration – i.e. permissiveness, relative democratisation, open communication, shared responsibility and self-government. All of this requires an ego nucleus in the individual and in the group, and some degree of boundary control function in both.

There is a parallel argument put forward by Winnicott when discussing what makes democracy work.

“In maturity environment is something to which the individual man or woman takes responsibility. In a community in which there is a sufficiently high proportion of mature individuals, there is a state of affairs that provides the basis for what is called democracy. If the proportion of mature individuals is below a certain number, democracy is not something that can become a political fact since affairs will be swayed by the immature, ie. by those who by identification with the community lose their own individuality, or by those who never achieve more than the attitude of the individual dependent upon society.

At the Cotswold Community we have found that it is possible to measure the level of integration attained in individuals and the consequent level of ego functioning in the group. If this is too low, staff survival is threatened. Where the confidence and morale of a staff team are low and the level of damage in the client is high, staff will become impoverished and break down. With this the level of reliability and containment will be lowered, and acting out in one way or another will increase. A way out of this vicious circle is to adapt the treatment milieu to the needs of the clients. This means redefining the primary task, recognising that the treatment needs of the unintegrated are different.

Although this paper is based on the residential treatment of children and young people, I feel that the concept of integration is also relevant to adult therapeutic communities. A significant proportion of unrecognised unintegrated clients in a group may have contributed to the demise of therapeutic communities in the past.

References

BALBERNIE, R. (1974) “Unintegration, Integration and Level of Ego Functioning as the Determinants of Planned Cover Therapy, of Unit Task and of Placement” Journal of the Association of Workers for Maladjusted Children 2.1
DOCKAR-DRYSDALE, B.E. (1968)) Consultaiton in Child Care. London:LKongmans
DOCKAR-DRYSDALE, B.E. (1973) Therapy in Child Care. Londin: Longmans
WINNICOTT, D.W. (1988) Human Nature, London: Free Association Books
WINNICOTT, D.W. (1965) Group Influences and the Maladjusted Child in the Family and Individual Development. London: Tavistock