Greenacres (Calne, Wiltshire), formerly a Community Home with Education (CHE) and prior to that an Approved School, no longer exists. Isabel Menzies Lyth, who was already a consultant to the Cotswold Community, was brought in to consult on the attempt to transform Greenacres from a “run-of-the-mill” CHE to a planned therapeutic environment. I have deliberately not used the term “therapeutic community” because I don’t recall that being on the agenda. I think this document is a very good example of Isabel’s style of management consultancy.
Naming it “management consultancy” doesn’t do justice to the breadth and depth of the knowledge and experience she brings to this role. It is also a good example of how the production of “Working Notes” following a period of intense consultancy work, identifies “work in progress” and the agenda of work she would expect the staff team to pursue between consultancies.
Working Note No 1: 15 July 1980 Isabel Menzies Lyth
I shall try to set out in this introduction some of my own background thinking about the nature of the task of Greenacres and to show its implications for organisation and task performance.
I shall use AK Rice’s concept of primary task ie the task for which the organisation is set up and on the effective performance of which its survival depends – or perhaps more correctly should depend. Stated very broadly, the primary task of Greenacres as I see it is the provision of therapy for badly disturbed and damaged children and adolescents. The task can be divided theoretically and into three related components: import ie admission, conversion ie the therapeutic process; and export ie discharge or the transition of the hopefully improved adolescent back into the community at large. My work at Greenacres has been concerned so far mainly with the conversion process, although sorties have been made from time to time into the other two processes. This note will, therefore, be concerned with the conversion process ie the nature of the therapy needed by clients, how far these needs are met at present in Greenacres and what developments may seem desirable. (I find it difficult to find a more appropriate word than clients – they are not all children nor are they all yet properly adolescents, but to keep referring to boys and girls seems unduly cumbersome so I shall use ‘clients’.)
The nature of the clients’ problems
I shall comment briefly on the nature of the damage the clients have suffered, how this is reflected in the problems they bring to Greenacres and what, therefore, needs to be dealt with in the therapeutic process there. I suppose it is fair to assume that the vast majority of the clients have suffered from severe early deprivation of one sort of another: single mothers themselves inadequately supported or other forms of inadequate mothering, broken homes, significant early separation from their mothers and homes. Further, one can probably assume that these early experiences have not been adequately dealt with in their subsequent experiences, many of them having been cared for in day or residential nurseries or continuing in their inadequate home settings, not much helped by their schools and having no previous treatment. Indeed, their subsequent experiences may well have compounded the early deprivations. The delinquency or other bad behaviour that brings them to Greenacres may even be seen as a protest against what has happened to them or an abortive attempt to put things right. I well remember a colleague of mine who grew up in Glasgow remarking that the delinquents were among the healthy population of the Gorbals – they were still fighting. Not that one would encourage the delinquency, but merely note that within the delinquency there may be some seeds of recovery if they can be properly harnessed.
It is only too obvious that the client population as a whole is suffering from a dearth of good experiences – the danger of that obvious view is that no further analysis may be made of what constitutes good experience, and that the cure may be seen as the provision of ‘good experiences’ normally interpreted as a good deal of ‘loving’ care and gratification. Nothing could be less likely to be therapeutic unless it is appropriately supported by other perhaps harsher seeming measures. What else do the clients need or lack? What constitutes really good primary experience? As a result of inadequate primary experiences, they suffer from inadequate ego-formation, the origin of which lies often in an identification with a mother or other primary caretaker(s) who have themselves an inadequate ego and are, therefore, not a satisfactory model for such identification. Symptoms of this in clients are a real confusion about identity. They have little idea who they are and some of their acting-out can, I think, be understood as an attempt to provoke a powerful reaction from the other which will at least give a temporary feeling of a boundary between the self and the other. The confused sense of identity is also connected with primary experiences in which the caretaker herself has not established adequate boundaries and a real sense of identity. She confuses herself with the baby and leaves him confused. So, lack of boundary between the self and the other and inadequate control over one’s own boundaries is a major problem, one which is closely linked also with immaturity in the use of both projection and introjection. Parts of the self which cannot be managed – and these are massive in these clients – are split off and projected into the other with consequent loss of real appreciation of the self and the other. The other is not seen as he is but according to the projections into him and he may truly find it difficult not to be controlled by the projections and become like them. I am sure this experience is very familiar to Greenacres staff. Introjection, too, 3 is inappropriate, often being characterised by excessive greed and demandingness and the need for immediate satisfaction, no waiting. It can also be used in the service of temporary, inappropriate pseudo-identifications in the search for an identity as shown, for example, in unrealistic career ambitions in identification with an ‘idol’, attachment to ‘sects’, often delinquent, and so on.
The lack of secure identity and of adequate boundaries can also be seen in a difficulty in taking effective responsibility for the self, for one’s own decisions and one’s own behaviour. This may in turn be linked with powerful acting-out without real appreciation of its consequences or any apparent concern for others who are involved. It may also be linked with a severely damaged timesense, the past, present and future not being really connected up so that the concept of the past having consequences in the present or the past and present consequences for the future does not really exist. This inevitably diminishes the client’s control over himself and also makes it harder for others to control him, appeals to reason or to an appreciation of consequences not being effective.
The capacity for attachment, love and care is also damaged or underdeveloped. The clients will tend to lack real attachment to primary figures (sometimes shown, however, in excessive and sentimental attachment and clinging.) They cannot give love and care to others and tend to respond inappropriately when others offer it to them. A symptom of this is a patter of making fleeting, often apparently intense but superficial and meaningless attachments, quickly abandoned for others. A colleague of mine has described vividly a model for this pattern in the care given to children in day and residential nurseries. The nature of the care system is such that no child can expect more than a fleeting moment of attention from an adult and he sees other children getting only these fleeting moments of care. Relationships are disparate and lack continuity and the child identifies with this model of the adult and of relationships. So he too develops a pattern of disparate and fleeting relationships without deep meaning – what I have called the butterfly phenomenon. And this pattern extends beyond personal relationships, appearing also in a pattern of short-lived play activities or later in a difficulty in concentrating at school. The child has no model for continuous attention. By about the age of seven, if not earlier, such children are in trouble at school because they cannot concentrate and the problems are still very evident in the school at Greenacres.
I have made a number of references in what I have said to what could be called superego problems eg lack of authority and responsibility for the self and one’s decisions and actions, a lack of appreciation of the consequences of one’s behaviour. The superego problems are severe in such children, being linked with the presentation of inadequate superego models, failure of the superego to mature and the persistence of a primitive and very sadistic superego. This tends to be intolerable to the immature ego and is consequently projected. So the person acts without superego control and tends to provoke excessively punitive behaviour from those into whom he projects it – the aggressor view of the distressed and disturbed child.
My final point returns to the learning difficulties of clients which I now put into a broader framework. Learning difficulties tend to overshadow their whole lives, their capacity to learn from experience is underdeveloped or badly damaged. This is again a function of inadequate care in the early years. The foundation of the capacity to learn lies in the relationship with the primary caretaker: if she fails to provide the opportunities the damage is done. The processes are subtle. The mother provides a model for the child of how to deal with experience and learn from it. She takes in his communications about how he feels, works them over in herself, sorts them out, assesses the relation of his feelings with the reality of what is happening and communicates back to him a more realistic view of the situation and more appropriate feelings – in the earliest phases, of course, in the language of physical contact not words. The ‘ordinary devoted mother’ (Winnicott) thus helps the child to learn the reality of his world and its meaning and in identification with her he learns to learn for himself, to assess its meaning for himself, to act appropriately in it and to take responsibility for his actions. The foundations of educability in its broadest sense are here. She also teaches him how to cope with fears and with doubts and uncertainties, to tolerate when necessary the unknown – a capacity notably absent in Greenacres clients, who are beset by fears of the unknown and find doubt and uncertainty very difficult. Successful mothering also breeds the constructive curiosity and pleasure in exploring the as yet unknown that are basic to learning. Bion, whose formulations I find helpful, describes the process as one of containment. The mother acts as a container for the baby’s communications, the contained, and processes them by what he calls maternal reverie, an intuitive thinking and feeling process closely linked with her love for the baby and his father. The mother returns to the baby, now the container, the results of her reverie, now the contained in the baby. Thus, he takes in not only a modified, worked over version of his own feelings communicated to her but also a model of the process through which this is done and with which he identifies in developing his ability to do it for himself. Greenacres clients too often lack this model.
The mother’s capacity to perform this function depends not only on her own inherent capacity but also on the support she herself has in her environment, the help she can mobilise to deal with her own feelings and fears as well as those the baby communicates to her, from her husband, her mother or other relatives, friends and professionals. The absence of such support contributed notably, for example, to the difficulties we found in many isolated single mothers of day nursery children in ‘containing’ their babies and small children effectively, and providing appropriate models for their development.
The capacity to learn from experience is of the essence here, and to learn from both good and bad experiences. None of us, fortunately, entirely escapes from bad experiences – and if we did we would never learn to cope with them. Bad experiences as well as good can be put to good developmental account if we can contain and digest them. We found this in the orthopaedic hospital where a significant number of the children and their attendant mothers matured visibly from what was at times a truly terrible experience for both. This is partly why I questioned above the provision of 5 love and gratification alone as the therapeutic instrument. With Greenacres clients, the opportunity to learn from bad experiences, both past and present, is likely to be as important or even more important than the provision of current good experiences.
So much for the individual developmental deficiencies, but these in themselves contribute to another problem in working with such clients ie that their very developmental deficiencies predispose them to coalesce in groups that are dangerous and anti-developmental. This can be linked with what in approved school language would usually be referred to as sub-cultures. But I want to comment on particular forms of this as described by Bion under the general heading of basic assumption groups. These are characterised by false beliefs about how tasks can be accomplished, by powerful psychotic phenomena and often by acting out. They do not believe in accomplishment by work, through the pain and suffering in work or the elapse of time necessary for growth and accomplishment. These latter phenomena are characteristic of what Bion calls the work group. There are three basic assumptions described by Bion, all of which are evident in the Greenacres clients and only too easily colluded with by staff unless they are very much on their guard. Firstly, basic assumption dependency, ba D; the group seeks or believes itself to have found, or to deserve, a god-like all-providing figure who will solve all their problems and provide for all their needs without the group having to make any effort itself. Clients to be gratified and staff to be allproviding. Secondly, basic assumption fight or flight, ba FF; one will solve one’s problems by fighting against a chosen enemy, eg society, which is held responsible for one’s troubles – hence the client’s delinquency or a possible staff view of the client as the helpless victim of society who cannot be held in any way responsible for his own plight or do anything about it himself. Or flight – to get out of the situation which is causing the trouble and demands work to deal with it. The client will escape if he can eg by absconding. Any staff may collude with this view of removing the client from the trouble spot and putting him somewhere else rather than helping him stay and work through the problem. Finally, basic assumption pairing, ba P, in which the hope of solution is placed in a pair while the others sit by and watch. It is characterised by vain hopes that something good will at last emerge from the pair without one actually doing any work towards a solution oneself. I suspect that ba P may only too easily creep into the key-worker/client relationship and other people feel absolved from work with that client.
One problem about the basic assumptions is that of distinguishing between situations where dependency, fight/flight or pairing are actually useful and work orientated and when they are not. Dependency can realistically take place in a work situation, eg between mother and baby. Fight may be desirable to accomplish a work objective. Flight may be judicious – to live to fight another day. The pairing in a good marriage is oriented to the work running the family. But one can learn to sense when these phenomena are useful in furthering task and when they must be tackled as anti-task.
The relation of the personality problems to the therapeutic task
I am sure my description of the problems of the Greenacres clients has not been exhaustive but it takes up most of the points I wish to cover in trying to discuss the conversion process that may, hopefully, lead to some recovery.
Broadly, I see the therapeutic task as the provision of a therapeutic milieu into which the clients come, the therapeutic milieu being considered in the broadest sense. All aspects of the way Greenacres functions and the behaviour of all members of the community, both staff and clients, must be viewed, therefore, as potentially therapeutic or anti-therapeutic. (I would add, perhaps, inconsequentially, therapeutic or anti-therapeutic for staff as well as clients, since my experience has been that an organisation that provides a good therapeutic milieu for clients also contributes to the further growth and development of staff. Perhaps it is not so inconsequential after all, because this means that staff become better models for clients to identity with – see below). The clients come together in Greenacres to live and work with each other and staff in a milieu which is therapeutic. Living is centred primarily in the care units and work in the school but too firm a distinction between those two would be false and anti-therapeutic. Living in the community goes on all the time and so does work of one kind of another, whether it is work in helping run the households or, more pervasively, working at problems. ‘Work’ needs to be done by clients at living at Greenacres.
In a sense, this implies that the whole institution is the instrument of therapy rather than the more usual understanding of the term that therapy is given or done in this or that way. The way the instrument operates can be broken down into a number of different aspects, some of the most important of which I shall now discuss, taking as a central theme the way that staff can provide good ego and superego models with which the clients can identify as an aid to recovery. I shall also consider the organisational task of providing the containment and reverie so important in the development of the young child.
I begin with the problem of identity and the inadequacy of personal boundaries in the client. He needs to experience firm external boundaries continually so that he can begin to internalise this experience and feel the benefit to himself of personal boundaries which contain him better and give him more sense of self. The boundaries will be both physical and psychosocial, and both space and time boundaries. Clients need to be enclosed in defined spatial territories, eg bounded living quarters like normal homes with control over entry and exit. They need also boundaries over time, for activities, for events, regularities in happenings, to help them appreciate the links between past, present and future, to learn to wait and so on. The boundaries will be permeable, of course, and the systems they enclose are open systems in communication and mutual transactions with their environment, but such movements across the boundaries need to be monitored so that they facilitate the therapeutic task and do not disrupt it. In addition, what lies properly inside and what outside the boundary must be clearly defined and adhered to as closely as possible. The boundaries in question apply to many aspects of the institution:
(i) The external boundaries of the whole with effectively controlled movement across them, whether it be the import and export of clients, the arrangements for visitors, the provision of supplies of various sorts, staff selection or discharge, or whatever. Transactions across the external boundary are many and varied and especially need to be effectively monitored.
(ii) The sub-systems of the whole, the Principal, the Head of Care with the care units, the Head of the School with the school, Mrs Wright and her department, the leisure coordinator and leisure activities, estate maintenance. There may be others but these strike me as the most important. Again these boundaries are permeable and transactions across them need to be monitored in relation to the task of each sub-system and what is or should be outside and inside defined, and all in relation to the primary task of Greenacres, the development and maintenance of the therapeutic milieu.
(iii) The boundaries of delegation of authority, of roles, functions and tasks need to be defined so that staff know where they are, who they are and what they are at any given moment. This is important in a situation where staff inevitably carry multiple roles and where it is, therefore, important that they know what is their primary and operational role at a given time and what authority, functions and responsibilities are in that role, so that they do not slip over as is only too easy into muddles about authority, functions and behaviour. This may be especially important where people whose primary base is in one sub-system, eg the school, move temporarily into another sub-system, eg care or leisure, and should come under another authority.
(iv) Finally, there are the boundaries of the individual. The clients, as we know, have serious boundary problems, with their excessive and primitive introjection and projection systems. The staff have, therefore, a special task in sustaining the intactness of their own individual boundaries – not an easy task and one in which failure will inevitably happen repeatedly. In so far as they succeed they, ipso facto, help the clients know where their own boundaries are, what belongs properly inside and what outside. The firm establishment of the other boundaries as discussed above will help staff in this task. Otherwise, much of the sustaining of adequate personal boundaries by staff depends on their developing sensitivity to the projections made into them by others, especially but not only clients, and to the appropriateness of introjections from them and identifications with them. For example, one can recognise projections into one by a feeling of strangeness in oneself, unwanted feelings or a strong impulse to act in a strange way. ‘That was not me’ puts it in a nutshell. This can help one recognise what has been put across one’s boundary and put it back where it belongs. Inappropriate introjections can similarly be recognised, the obverse sometimes of the projections. They can be recognised by sudden changes in the other – the client suddenly becomes 8 too like a staff member, by a process like mimicry not by a process of growth and identification. It need hardly be said that staff have to be on guard also about their own projections into others sometimes felt as a loss of self, and about their own inappropriate introjections.
The process of establishing effective boundaries also contributes to improvement of other personality problems. For example, it facilitates containment. Staff and client alike are more firmly held within organisational and personal boundaries and people are less all over the place. And both the organisational and the staff working in it present better models of containment with which clients can identify to improve their own capacity to ‘contain’ themselves and their own behaviour.
The effective containment of staff within organisational and personal boundaries also facilitates the organisational analogue of maternal reverie, an experience desperately needed by clients. The sustaining of boundaries and effective management of transactions across them and within them can be seen as analogous to the position of the ordinary devoted mother supported by her environment within the boundaries of her home, her extended family, and appropriate professional relationships. It helps staff to take in the disturbed communications of clients, both individually and in group situations, to be felt and thought about, and to be talked out with each other and with the clients. All my institutional experience suggests that the way the organisation functions in this respect much affects the capacity of the staff member or staff members working together to carry out the process of reverie. And one important consequence is that successful reverie diminishes acting out of the impulses that are now contained and worked out.
Another important consequence of well-defined boundaries is the facilitation of appropriate identifications and the firmer establishment of individual identities. People do not, it seems to me, identify with large organisations directly. Their identification is primarily with smaller, face-to-face groups and the individuals in them, and only through that to the whole organisation. The more easily identifiable the small groups are and the more appropriately contained they are, the stronger the identification with them, and with the whole organisation through them, is likely to be. This gives a sense of belonging to something that matters, a feeling notably missing in the experience of Greenacres clients.
I would like now to move on to discuss organisational features connected with the development of more mature authority over the self in clients. This will concern particularly the models of authority provided by the staff and by the organisation itself. Much of what I wrote above about the definition of authority, roles, functions and tasks applies here also, and concerns the provision of conditions in which the staff can feel secure about their authority in role and can behave authoritatively. Thus staff can be seen to behave authoritatively and to take personal as well as organisational responsibility for their own actions. At the same time, staff are helped to accept the authority of the organisation and of their superiors so that they present models to the 9 clients of co-operation with the acceptance of appropriate authority. Such authority needs to be benign, of course, and ultimately democratic, authoritative not authoritarian, based on shared work towards agreement on basic principles and policy, otherwise the authority will not be accepted and reflected towards clients, and sub-cultures could develop only too easily. I am here, of course, formulating differently the above point about the presentation of good ego and superego models to clients.
I shall now consider the provision of opportunities to improve the client’s capacity for attachment. Here again, improved boundary control is a good start, holding him in a situation where he is likely to have closer and more continuous relationships with the same staff and other clients. Contrary to widespread belief – a caricature of Bowlby’s work – a healthy attachment development does not mean attachment to only one figure but to a focal figure along with a number of other meaningful attachments, eg mother, plus father, siblings, grandmother, family pets, the woman next door. Such a situation is comparatively easy to replicate eg in a care unit to a focal key worker, to other staff and clients and with other attachments outside, eg in the school. The process of developing these attachments is complicated especially since it is likely to involve swimming against the tide a good deal of the time, ie against the poor attachment capacity of clients. It involves certainly the provision of good experiences particularly those in which staff and clients can enjoy themselves together. All sorts of opportunities present themselves, good food provided with care and concern and eaten together, play or games enjoyed together, watching television and so on. The danger in this aspect of attachment provision is that it may slip over into ba D in which anti-therapeutic gratification may take over. And in any case, it is not enough. A most important aspect of the development of attachment is the provision made for dealing with disturbance and distress, holding the client securely through them, providing reverie. In the case of Greenacres clients it will involve confrontation with disturbance and meaningfully working it through without evasion, without undue fear, and with honesty and concern. Especially, it will involve confrontation with ephemeral and superficial attachments that they may make and helping them towards more real attachments with all the pleasure and pain involved, taking the good with the bad.
A lot of what I have said involves also the process of learning to learn from experience. I shall bring it together briefly here to show something of how it fits into the picture. Very importantly it resides in the provision for reverie by staff for and with clients, in the holding and containment aspects of attachment formation, in the provision by staff of models of people who can confront experience and learn and mature through it, staff who can confront doubt and uncertainty and who display a constructive curiosity, especially a concerned but non-intrusive curiosity about clients and their experiences. This would help avoid an artificial split between the school where one learns and the rest of Greenacres where one lives, plays and so on. Each success for the client in this process strengthens the capacity to go on doing it. Not all improvement in learning in the school will come from work in the school. Some will come from other areas in so far as all are orientated to learning from experience.
I have known dramatic improvements in a child’s school work come from therapy alone without any special action being taken in his school or direct attention to school work.
My last point in this section concerns the control of sub-cultural developments – an activity again doomed to much failure but which must be pursued nevertheless. I have already mentioned the danger of the provision of good experiences passing over into ba D which is anti-maturational, too much being done for clients and not enough expected of them in the way of self-provision, for example, or in tolerating frustration.
The other two basic assumptions are only too prone to appear also, often a function of the way the organisation operates. It is easy for example, for staff to be caught up in paranoid or delinquent attitudes and behaviour as a result of institutional forces. The control and dispensation of resources from a point outside their area of use is one such organisational feature. Paranoid attitudes easily develop towards the outside authority which is regarded as mean and often whimsical in the way resources are allocated. Manipulating one’s way round or even cheating becomes an acceptable way of handling the situation, but this is delinquent and presents a very bad model to already delinquent clients. Ba d may also come in here as people complain that the provider has not given enough – all that is wanted – instead of taking a mature responsibility for the best use of scarce resources. Ba FF is shown in the fight against authority and the flight from responsibility. By contrast, control of resources at the point of use not only tends to disperse these phenomena but also increases the authority of the staff concerned and facilitates confrontation with the clients about their use. Inappropriate pairing may also appear among both staff and clients, eg an anti-task pairing between disgruntled staff members not orientated to work towards examining grievances but to the relief of bad feelings or the strengthening of one’s own sense of being right. Similarly, pairing among clients may not contribute to growth but further mutually supported acting out, sometimes though not linked with inappropriate sexual activities. These are linked to unrealistic hopes of problem solving in the pair and avoidance of the pain and work of real problem solving So vigilance needs to be given to the relation of pairing to task, two staff working effectively together or a friendship between clients that is really maturational. Only by developing intuition again can one learn to know the difference and whether to tackle the inappropriateness or support the appropriateness of the pair.
The work at Greenacres
The concept of the therapeutic milieu summarises the task of Greenacres for me, and I hope I have given some leads as to how it may be realised. Tasks on which a start has been made in care units include the following:
(i) The clarification of roles, tasks and functions within the care units. A number of household tasks such as catering, maintenance and control of clothing allowances have been separated out and delegated to staff members with varying 11 success in different units. Some of the incumbents of these roles need some help in tightening up their control over their tasks either from the head of the house or from some appropriate person outside such as their opposite number in another house. Houses also have deputy heads but some further work probably needs to be done on deputising for the head as distinct from the deputy role, eg to be certain that in the absence of both head and deputy someone else is appointed temporarily but clearly in charge.
Much more confusion seems to exist in the therapeutic and care aspects of the task, notably between the key-worker, the care team and the staff as a whole in relation both to individual clients and to the client group as a whole. I believe my own thoughts are now fairly clear on this. I do not think that the intervention of the care team between the key worker and the whole staff is really necessary or even helpful. It does not seem to work well in practice, being hard to fit in with duty rosters. Nor do I find it helpful in the light of attachment theory. The whole staff is not too large for some attachment to be formed to all of them although these will vary in intensity. And clients and staff are likely to exercise some choice as to where they will form attachments, quite appropriately. It would not seem desirable to interfere with these. Multiple attachments round a focal figure are a normal family pattern and in the absence of the focal figure the other attachment figures can be a very good substitute. But I found staff somewhat uneasy about these multiple attachments in units, linked with some misunderstanding of attachment theory and seeming to believe that there should only be one attachment to the key worker and that other attachments would interfere. They seemed to feel they were breaking some unwritten rule if they fostered other attachments or stood in for the key worker in a helpful and concerned way. Nothing could be farther from the truth as I see it – in the often fraught situation work may need to be done immediately by the most available staff member and cannot await the key worker. But work may also have to be done by staff at calmer times if the most is to be made of the attachment opportunities, eg tackling rivalry and jealousy between staff members about clients or helping to control the undoubted skill of clients playing one staff member off against another. So I see the structure in theory as the whole staff working together as a group, some on duty and some off duty and with the key worker having his special role within that setting.
Staff are still unclear, as indeed I am, about the components of the role of key worker. It seems clearest in relation to pre-admission and admission procedures, taking a major part in home visits at that stage and introducing the client to his care unit and helping him settle there. After that, the situation becomes more cloudy. I think one might try to clarify situations where the presence of the key worker with the client has special importance – pleasurable ones like possibly shopping expeditions or other outings, but also the more potentially traumatic ones like visits to the dentist or court appearances. Opportunities for talk are also important and would hope that the attachment begun during admission would predispose the client to choose the key worker for talk about important matters rather than others. This talk would be related to reverie and containment, giving the key worker the opportunity to exercise constructive curiosity about the client and get to know him and his background, to confront him with problems and help him learn from experience. Authority and discipline would also be involved. On the whole, I think the less contrived these encounters are the better, so that they develop naturally, taking place, for example, while other activities are going on when they may be alone together such as on outings. Clients may well not be too cooperative if the encounters are arranged too formally. And again, I would not be too uneasy if some of the encounters are with other staff – it may be important to seize the moment, and the key worker may not be available. There is the danger that the key worker role might let other staff off their responsibility for dealing with problems with a particular client.
The key worker should, however, be the person who knows most about the client, both from the client himself and from others who work with him, anywhere in Greenacres and also from outside. I would think that the collating of such information with written notes should probably be part of the key worker role. The collated notes could then form a basis for assessment of the client and his needs and of his position in the various sub-systems in Greenacres and for devising some appropriate form of treatment programme.
In the relation of the key worker role to other roles taken by staff – the same people – I think there is some confusion about the hierarchy of roles or the primacy of roles in different situations. The key worker while on duty in the unit is also a staff member at large, carrying other roles such as head of the unit or having a general responsibility for the running of the unit and the general care of all clients. There seems to be a tendency for the key worker role to take primacy over general staff roles, and I think this may often be a mistake especially where one client’s key worker is the only staff member available to a whole group of clients, when I think that task-primacy lies in the management of the whole group. I suspect this may be partly a hangover from the very individually based treatment programmes, and also reflects a tendency for staff to feel even more insecure in working with groups than they do in the key worker role, especially when the groups are in a state of disturbance or crisis.
I think there may be a need for consultant help in the following areas:
- Further clarification of the key worker role.
- Increasing skills and security in working with groups of clients.
- Clarifying the relationship between key worker and general staff roles and establishing primacy between them in different situations.
I have also found that the boundary situation around units is very unclear. The assistance given to boundary control by physical location and the nature of the premises varies greatly between units, being most effective in Springfield with its relative isolation and clearly defined premises and worst in Schoolhouse whose premises are all muddled and right in the middle of things. The boundaries of Paddock, in the intermediate position, would be fairly easily improved by the provision of fencing round a front garden which would distance the house from passing traffic and give a useful extension of living space such as is much enjoyed in Springfield. I find myself wondering if Schoolhouse could not be moved by some reallocation of existing buildings – I find its situation nearly impossible, like living cooped up in a high-rise flat.
Psychosocial control of all unit boundaries is, I think, a bit lax. I and others seem to feel free or indeed to be given the freedom to go out and in at will and that does not feel right to me. My standard is the ordinary home which controls its boundaries pretty firmly as a rule and gives unrestricted access to a few intimates. The units are the clients’ home. Unrestricted access seems to me too intrusive, threatening already fragile personal boundaries and it may well disrupt ongoing work. A tightening of the boundary might also help to keep clients more firmly inside it, knowing better where they belong. Even allowing for the fact that it is summertime and that people want to be outside, I have been struck by the number of clients just wandering about the place, not in relation to care staff in their units or engaged with them. A unit can carry its psychosocial boundary outside its physical boundary with benefit if such engagement continues. Firming up of boundaries would also, I think, facilitate improved communication and more effective transactions across boundaries, eg with the school. The whole situation seems too vague at the moment for people to know easily with whom to communicate about what.
Work has started on this but much more remains to be done on the clarification of authority boundaries around units and about what lies inside and what outside. Unit leaders vary in the authority they take personally, but there is much more to it than that. I see it as important to strengthen the authority of unit leaders over their boundaries and in their roles. Here an important factor is how much is contained within the boundary and how much that affects them is controlled from outside, how much they are and feel in control of their own destinies. The more they are, the more authoritative they can be. In particular, I think it important that they should gradually acquire control over most of the resources deployed in their units, if not all, the necessary safeguards and sanctions being devised. So all unit budgets might come under the control of unit heads who would be responsible for estimates and the effective use of all moneys allocated to them. Unit heads would have responsibility for the supervision of budgets allocated to other staff members such as catering or clothing. The Head of Care would have a function here too, both in the reconciliation of the needs of different units and final preparation of estimates and in ensuring that heads of units operate the system effectively, keeping proper accounts to the standard of the County Council, keeping within budgets, obtaining the necessary receipts, using the order book properly and so on. I do not feel that such tasks should be left to Mrs Hunt who, in the management hierarchy, has no management authority over care staff and who should not, therefore, be left accountable for their inadequacies to the County Council. She performs an extremely important service and monitoring task in relation to finance, while the management responsibility is with the Head of Care and through him to the Principal. It is probably necessary to work out effective monitoring and managerial procedures here with Mrs Hunt and the others concerned.
This again approaches more closely the ordinary family model, a family having its own resources, control over them and the responsibility for the effective use of scarce resources. This raises another important point, ie that staff develop a culture of working with scarcity and making the most of resources rather than blaming others for keeping them short, work rather than ba D. Several beneficial effects are likely to follow: resources are likely to be better used; staff can carry experience of coping with scarce resources into confrontation with clients, a useful preparation for life outside where resources are always scarce; the tendency to paranoid and delinquent attitudes in staff transferred to clients is diminished. The cooperation of various people outside the units would be needed here. It would affect Mrs Wright’s department in some ways and also some aspects of the Principal’s role and/or that of the Head of Care in allocating resources between units in what seems a rather ad hoc way as the need seems to arise – a form of activity that tends to evoke feelings of insecurity and anger in staff who see things they want or had expected to get disappear into other units. Having resources under one’s own control also helps to foster self-help and DIY activities as an aid to getting more out of resources, activities that can only be beneficial to clients – the more they can be involved with them the better. Gardening to supplement food supplies and decorating are examples.
I am also unclear about what for want of a better term at present I shall call internal consultancy, ie by top management to care units. I feel my lack of clarity may reflect the true situation. As I understand it, this function is performed for care units by all three members of top management. In the absence of an outside consultant this is probably an important function, but what I am not sure about is how far the people concerned are clear about the roles, authority relationships and tasks. I do not feel it can correctly be called management. It is a training, support and advisory service. If it is seen as management it crosses and muddles management boundaries, the Principal and the Head of the School stepping round the boundaries of the authority of the Head of Care.
The boundaries between the care units and also between them and other sub-systems, such as the school, are liable to be affected by the same phenomena as I have described in the clients, ie by anti-therapeutic projections and introjections. My attention has been repeatedly drawn to a repetitive pattern, that one care unit, not always the same one, is in trouble while the other two are moderately all right. I have found the same phenomenon in other places. The people concerned are rightly anxious about it since it represents not a reality but the projection of badness across psychosocial boundaries, and the encapsulation of goodness, often exaggerated, inside. This does not facilitate real work in either unit. Opportunities need to be provided to review the situation and to get the projections back to where they belong, reducing smugness on the one side and undue despondency on the other. A meeting of the heads of units with the Head of Care or a consultant might facilitate this. I think also that the mutual projections between Care and the school are not helpful to either and work could well be done on that when the new heads of both are in post.
As another afterthought, I feel I am uneasy about the constant use of the word ‘care’ – I am not clear how much this is me and how much I get it from Greenacres. The danger I feel is that it may make the operation too soft, too much concerned with trying to love and give and not enough with the harder aspects of confrontation and firmness and authoritative boundaries to hold clients.
And, finally, about care: I feel the units, variably, are too big. The bigger ones must be very difficult for staff and even more so for clients to encompass in a containing way. I do realise the difficulties of having more smaller units, but perhaps it could be looked at – one day.
I move on now to the school, about which I have much less ‘feel’ than the care units. The task of the school I see as the provision of education within a therapeutic milieu but I feel that the school has little developed conception of what that means, and I think there may be a tendency to view education with blinkers on and not to look enough at the setting that must be provided if educability is to be fostered and educational standards improved. My general feeling as I have been with teachers is of an ill-concealed chaos that makes teachers very uneasy, but leave them also feeling rather helpless to do anything about it The keynote of my meetings with them has been frustration which is attached to a number of things, inadequate opportunities to teach one’s own subject, inadequate control over the boundaries of one’s own task and the composition of the pupil group, a decided lack of control over one’s own destiny, the constant interference with one’s work arising from the absences of colleagues. My own feeling is that the considerable resources of the teaching staff in skill, experience and concern have not been effectively mobilised, indeed they seem to have been inhibited, and in consequence the teachers have tended to develop a culture of dependence in which they wait for guidance instead of taking the initiative – guidance which often does not come or, if it does, is often not liked. The labour turnover in the school and staff absenteeism are ominous signs that much work needs to be done after but perhaps also before the new head is in post.
The direction of the work is not at all clear to me, but I have some suggestions. First, there is the need to develop the concept of the therapeutic milieu within the school setting where, as I see it, many of the same features might apply as in care units; for example, the development of attachment between teachers and pupils, an important feature of normal school life. (A recent report on an experiment in helping prevent educational difficulties found when day nursery children get to school has shown the importance of giving each child his own fixed time each day alone with a concerned adult who talks and listens where perhaps for the first time the child may engage in an attachment where he feels himself significant.) Other such features are: concerned curiosity about pupils; the strengthening of the authority of the teachers over their own areas of work, something like an educational assessment for each child might be helpful to include not only his present level of achievements but also an analysis of his particular learning difficulties and how they may be overcome, the establishment of educability being the first objective rather than getting educated. Teaching programmes might also 16 be developed on this basis suited to the needs of each pupil – a special kind of remedial teaching with special attention of emotional needs. I have been told, for example, of pupils who cannot concentrate for more than half a minute – the lack of concentration seems the first problem to tackle. Again, the pupils desperately need success experiences to encourage them so tasks may need to be tailor-made to give challenge with success.
At the same time as avoiding the Scylla of rigid ‘educationalism’, one must also avoid the Charybdis of ‘therapy’ without education, educational achievement being therapeutic and a necessary preparation for life outside.
In contrast to what I have just said about the need for individual attention is almost the opposite. As in care units, I feel that a good deal more could be made of group situations as an aspect of providing the therapeutic milieu in the school. Teachers seem aware of the importance of handling their groups well, although in a rather unformulated way, but again seemed uncertain what to do about it. They seemed uneasy, as I am, about an apparently too great readiness to hive off disturbed or difficult pupils into the control group or the farm and sometimes would have preferred to struggle on themselves. They might need consultant help in developing their confidence and skills here in understanding, managing and putting to good therapeutic use the group phenomena in their classes, possibly putting aside strictly educational work while they do so.
On the whole, I think the boundaries of the school have been too rigidly controlled, movement across the boundary is not easy either from inside or from outside. It feels very encapsulated and in a curious way hardly a part of Greenacres – identification is not strong. I found my own entry quite difficult, not against me as a person, rather as an unaccustomed event. My explorations were blocked in various ways by too much talking at me by some people which made it difficult for me to explore in directions of my choice, or by great caution and reserve about what could be said. Things became more free in my second meeting with the teachers and I felt they began to be more able to let me into their preoccupations and their dissatisfactions. The rigid boundary notably affects relationships between the school and the care units – both tending to blame the other for bad communication. I was told that the school and care units had not interfered with each other which seemed to me a very curious remark. I rather felt they should – such interference might have shown a very proper concern for the way that clients in one’s own care fared in the other sub-system. Another desirable direction of work, therefore, seems to be in defining more effectively the boundaries between the school and the nature of useful transactions across them.
As regards other departments, a general remark first to recall what I said above – that all are inevitably involved in developing and sustaining the therapeutic milieu. But there is a distinction, nevertheless, between the other departments and the sub-systems most directly concerned with client care. The other departments are mainly responsible for providing a service to support these systems, school and care.
Mrs Wright’s department seems to function well with a very stable staff. As far as I could sort it out with Mrs Wright and care staff, the authority boundary seems clear and appropriate in relation to domestic staff working in care units, ie that they come under the authority of the head of the unit and not Mrs Wright, although she has a concerned and ‘professional’ relationship with them. I am less clear about the division of responsibility for clients’ medical care between Mrs Wright and units – perhaps this should be looked at again especially in relation to the key worker and attachment.
Areas where more work seems needed concern the further deployment of resources into units, both personal and financial resources at present under Mrs Wright’s control, eg further deployment of catering resources for domestic supplies. Some of these would involve quite delicate negotiations in relation to the feelings and loyalties of the staff concerned.
Mrs Hunt’s work I have already considered. She performs a vital service in administering and monitoring finance and seems to have it very well organised. But think of it as a service, not an authority or management function, and it is important that she should not be in danger of becoming a scapegoat for other people’s inadequacies or carry the can for the inadequacies of other people. It might help to clarify further the relationships and authority channels round her task.
The leisure system does not work well and I find I am less inclined to regard this as a failure on the coordinator’s part than as arising from the possibility that the role of leisure coordinator is a non-job. Sue Parker is herself dissatisfied with the way her work goes and I think feels herself bound and inhibited by forces she does not understand and cannot control. She feels she does bits of good work but not a good job.
My own feeling is that the setting up of this role may represent hiving off a task that may more properly belong elsewhere, notably in the care units who, I feel, should be responsible for coordinating leisure just as a family is. Not that this means they need necessarily do it all themselves, rather than they should know what is going on, how the clients use leisure and so on. It is another aspect of tightening boundary control. There are considerable resources at Greenacres that can be utilised for leisure – indeed their very richness must contribute to the leisure coordinator’s being a non-job. But I feel the care units need to be involved in clients’ choices and use of the opportunities.
The last major area considered is the top management system but limited work has been done on that in view of the resignations and new appointments to the head of the school and head of care. The details remain to be worked out with the new heads. However, I think I can raise some points for future consideration, some of which are little more than reiterating what has already been said. Firstly, there is the question of delegation: a good management principle is to delegate tasks and responsibilities as far down the hierarchy as possible, to the lowest point at which they can be competently carried. This is closely linked with the building of an authoritative staff and the growth of staff when tasks previously incorrectly thought to be too difficult for them are 18 delegated to them. Such delegation needs to be linked with review of performance. Thus, starting at the top, the head of the school and of care need to have full responsibility and authority for running these systems under the authority of and with review by the Principal. He in turn may need to be very circumspect about direct intervention in these areas in his management role, although he could come in on a training, support or advisory role. The danger of this concept slipping is greater, I think, on the care side, both because of the encapsulation of the school and because the Principal’s interests and skills lie more on that side and he has had a cooperative relation with the Head of Care. Management transactions with the staff of subsystems needs to be through the heads of systems if their authority is to be sustained, although other types of relationship may cross these boundaries, ie appeal systems or some sorts of disciplinary action. As discussed above, it would seem appropriate that the heads of systems control their own budgets.
Details remain to be worked out as well as the limits of this delegation. Similarly, heads of care units have delegated to them full responsibility for running their units, under the authority of the Head of Care. Again detailed work is needed to implement this. All service functions seem at present to be responsible directly to the Principal although they will have complex transactions with staff at other levels in the system. Some clarification of responsibilities and relationships here is probably also desirable.
The heads of all systems are responsible for the boundary control of that system, although other people will be involved in transactions across it. He needs to ensure that these transactions further task. The Principal has a particularly important task in controlling the external boundary of Greenacres. He has to ensure protection of the task from outside interference and be vigilant that all transactions are appropriate to furthering the task.
Internally the head of a system or sub-system should probably have responsibility for the following, some of them in cooperation with superiors or other sub-systems: budgetary control and resource deployment; standards of work; staffing; participation in client selection in operating units; policy-making; co-ordination of policy and transactions between systems. Detailed work remains to be done.
To conclude, I am left with a kind of ragbag of problems that have been brought to my notice but on which little or no work has yet been done. They include:
(i) The system of internal meetings and their relevance to task performance.
(ii) Consultancy needs: It is clear that my basically management consultancy is not enough, being limited both in scope and by the time available. Consultancy seems necessary for the tasks of client care both in the care system and the school, linked with staff support and training.
(iii) The treatment programmes formerly prepared do not seem to have been felt as very useful, but staff do seem to feel the need 19 for some appropriate form of client assessment and guidance from this in their work with clients. An appropriate form of regular review of clients does seem desirable, possibly in conjunction with the consultant as above.