“UNITED WE STAND…..?”
Stress in Residential Work with Disturbed Children
Monica Lanyado Maladjustment and Therapeutic Education, Vol 7, No 3
This quotation, “United we stand, divided we fall”, (from a speech by Winston Churchill), is not intended as a rally cry, but as an attempt to raise some key questions that we need to consider regarding staff support and development. For example: – Do we really need it? and if so – Why? If we need support in our work – then why doesn’t the butcher, baker and candlestick maker also need support? If we don’t help each other in our work with the children in our care, does it necessarily mean that the second part of the quotation “divided we fall” is a natural consequence?
The answers to the questions may to some extent seem obvious. However, I feel that in order to gain some real conviction about giving our professional needs the attention they deserve, we need to examine and debate these answers, and put them within a theoretical framework which makes sense to us. Otherwise “staff support and development” is merely an empty exercise, to which lip service is paid, instead of being a valuable part of the therapeutic system within which we all function.
Anyone who works with “the public” as opposed to producing manufactured goods, or creative works, has to learn how to accept behaviour from other people which in their private lives they would not find at all acceptable. “The customer is always right” – is the advice often offered to (but not always taken by) anyone wishing to do good business. In other words, whether you are a shop assistant or a captain of industry, there will be many occasions in your working life when your own feelings must be put aside in order to carry out your work effectively. The problem is – what happens to those feelings? Does one simply go home and take it out on ones nearest and dearest? Alternatively could it be that the feelings aroused and not expressed during the day could get stuck inside the individual, possibly leading to symptoms of tension? Over long periods of time chronically stressful work situations can lead to well documented syndromes, such as executive coronaries, addiction to tranquillisers or, excessive reliance on alcohol and other such stress relievers.
General Practitioners know that many stress symptoms become converted into bodily ailments. It is more socially acceptable to be “ill” than to be emotionally debilitated. High stress areas of work, such as working in Special Care Baby Units or Generic Social Work Departments suffer from high sickness rates and high staff turnover. It seems that people can generally only stand a certain level of stress for so long, before they develop their own, at times unhelpful, personal defences against the attacks they feel that they are under.
I would like to suggest for the purposes of this paper, that there is a continuum along which we can visualise the intensity of interpersonal stress in different work settings. At one end of the continuum we could place work activities that have a very clearly defined task – such as a car mechanic changing a gearbox. This is a practical and intellectual task – demanding of the intelligence of the mechanic, but not of his heart. Maybe a bit further along the continuum we would find people working in those business areas, where there is a clear product that is sold or a definite service offered, such as a waiter in a restaurant. The task is still clearly defined, but some interpersonal skills are necessary to do it well.
Further interpersonal skills are needed when team work is required to reach a common goal. A design team in Industry working to meet a customer’s specifications needs to mobilise the close co-operation of the team members, in what Bion (1961) refers to as a “work group” structure. Creative individuals are bound to clash at times in this situation, and will need to be able to resolve their conflicts so that they can continue to work together. Management courses increasingly recognise the importance of “people management”, and relationships within organisational groups. If these interpersonal and group dynamic factors are ignored, the ultimate productivity of the company will suffer. Authoritarian lines of management may create compliance, but they do not encourage innovative thought which is so necessary in the market place today.
Naturally, the more we move along the continuum towards a work culture in which the “product” is people-centred, the more important is the capacity to relate well to other people. Consider the medical profession. Training to become a doctor takes many years of intensive study. High intelligence is essential, as is dedication. The motivation to alleviate human suffering must be enormous, and yet one sadly all too often hears of apparently callous behaviour towards patients. It is as if the humanity of the patient is forgotten, and people in hospital can all too easily become known as “the duodenal ulcer in bed 9”! The human factor is almost deliberately drilled out of medical students in the name of professionalism. Why has this come about?
Balint (1957) and Menzies-Lyth (1981) have both written fascinating studies of the defences that the medical profession finds itself adopting – in order to survive the impact of the work. In other words, what we see is a defence mechanism which the medical profession adopts, (often quite unconsciously) that has become incorporated into the organisational structure. This defensive behaviour and system protects doctors and nurses from being overwhelmed by the anxieties inherent in their work. Constant contact with suffering, tragedy and death, in the raw, is intolerable. The defences adopted are a survival mechanism which enable the medical profession to continue in their work.
It is very easy to throw stones at other professions about their at times apparently nonsensical professional conduct. And of course, there has to be a better way than “non-caring”, to survive in a “caring” profession. It is all a question of balance – and indeed the medical profession is increasingly aware of the need to behave more sensitively towards patients, whilst not drowning in the emotionality of some peoples’ sad predicaments. Defences can be modified if the underlying capacity of the individual to tolerate anxiety can be enlarged. In my understanding this is the core of the problem. We are now talking about personal growth – be it in a Consultant Paediatrician, or a professional working with disturbed children.
If we stop to examine the defences which we employ to cope with our work, I don’t think we are in any position to preach! We are as resistant to the often painful process of personal growth as the next person and would much prefer to hide behind our defences. But we cannot possibly do our job well unless we constantly strive to respond to the children’s needs. They force us to change as much as we try to get them to change. If the children do not experience us as adults honestly striving to accommodate to, and understand their needs – what kind of model of change and growth do they have to identify with? We have to be as open and receptive as possible – but in the process of doing this we often get wounded. Staff support and development is there to help us tolerate these wounds and learn from them – that is to increase our capacity to cope with anxiety. However, this is not an excuse for masochistic surrender. It is a plea for learning from experience – which inevitably hurts a bit.
Our very varied personal and often unconscious motivations have led us to seek to help deeply unhappy children. We have followed our various trainings, read many books about them, written essays on them and then comes the onslaught of the actual experience of them! How is one to survive them – let alone help them? It is very easy in such circumstances to erect rigid defences which can block the use of the theories which tell us why a particular child is so ghastly to be with. In the heat of the moment, when one is being verbally or physically abused, or rejected, the natural instinct is to defend oneself, and to forget that the abusing child has been frequently abused in just such a way by significant adults in their life. They are simply giving us a taste of what their life experience has been about. Can we bear to receive such communications – in the raw? And if we can, what do we do with them? So often staff become hurt and bewildered by children’s consistent lack of concern, and cavalier attitude towards them. It is often a very long time before a child can show appreciation of the care and time given to them. It may only come at the end of several years of hard work. Meanwhile staff have to struggle on with abuse heaped upon abuse – hardly an encouraging job to the faint of heart!
In a paper of “Residential Management of Difficult Children” D W Winnicott wrote in 1947,
“It might be asked why …get emotionally involved? The answer is that these children….do not get anywhere unless someone does, in fact, get emotionally involved with them. To get under someone’s skin” (my emphasis), “is the first thing these children do when they begin to get hope.”
I am not advocating a kind of wholesale, no holds-barred type of emotional involvement – as I am sure Winnicott was not. I am trying to describe a considered and thoughtful awareness of how one feels, professionally, about the relationship with a particular child. This requires careful, honest sifting of what belongs to one’s own personal propensities when forming relationships – such as being touchy over certain matters, or insensitive over others – from what is evoked by that particular child. It is in this respect that staff support is so important – in helping to differentiate the child’s communications from the internal “noise” of one’s own emotional system. We need to be sensitive, highly tuned receptors, and we have to learn to listen carefully not only to the child’s communications, but also our colleagues.
I’m going to give examples of several fairly typical school events, with the emphasis on the staff interactions. They are put forward to illustrate the kinds of stressful situations which will be recognisable to all who work with children (and adults) in closely knit communities – such as hospitals, day centres, special day schools and residential schools. The first two examples relate to intra and interpersonal conflicts.
Example One – Attachment, Separation and Loss in staff members
Consider the situation in which a child has spent two years in a care group and formed a close but often violent relationship with one particular member of staff, whom he seems to save his worst outbursts for. Although he puts that adult through hell at times and has actually drawn blood on one occasion, she is nevertheless often heard to say – “but he’s a lovely child – and I feel so sorry for him, he has had so little to build on until now”.
When this child moves to another care group – part of growing up – the original care worker is likely to miss him, to wonder if his new care worker can understand him as well and handle him as “carefully” as she did. At times she may well feel critical of how he is treated, feeling she could do it better. Feelings of rivalry, loss and anger may then be powerfully experienced by the care worker. If in addition to this the child is also finding it hard to cope with the change, these feelings within the original care worker will be heightened.
If we look at this situation from the new care worker’s point of view the picture is rather different. He may well feel threatened by the previous closeness of child and careworker and may actually be having to struggle to find some attachment to and empathy for a violent child. The fact that the child appears to have got ‘worse’ since being in his care, heightens his anxiety that he may not be as good as the previous worker with this child. If these two care workers sit down to talk about the child’s problems, there is, for the staff, a complex and potentially distressing hidden agenda. Attempts by the past worker to help and advise, sound much too much like criticism to the new worker. Without the hidden agenda becoming more openly acknowledged, both members of staff are likely to become upset and defensive, making it difficult for them to cooperate.
Whilst we are usually highly aware of the significance of loss or separation from a loved adult, for a child, we do not often consider its counterpart. What does it mean to the adult to give up caring for a loved child? When a child has got under an adult’s skin, even in a highly ambivalent manner, it is not easy to hand them over to another member of staff’s care. And yet we are doing this all the time. Children change classes and change care workers, and particularly where that child has become special in some way to the adult, there is bound to be a feeling of loss.
A very similar combination of feelings has been described in staff terms, when a baby is in a Special Care Baby Unit, (Fletcher 1983). A number of Child Psychotherapists (Szur et al., 1981) working with staff in Special Care Baby Units found that when such an intense and life saving effort has been put in by nursing staff, it is very painful even though rewarding, to have to say goodbye to the baby when it goes home. Issues such as “whose baby is it?” are powerfully present during the baby’s stay in hospital. To remain in touch with such feelings is difficult and there is a temptation to become defensive, so that one doesn’t suffer such distress again. And yet for the baby in Special Care, and the disturbed child in a special school, the attachment of a member of staff to them, may be vital for their recovery.
Example Two – Disintegrating Child, Disintegrating Adults
Consider in the previous example, the possibility that the child really cannot cope with the loss of his loved carer worker and starts to disintegrate in Dockar-Drysdale’s terminology. Maybe he has suffered many previous losses but had begun to hope that he had finally found someone in the original care worker who could tolerate him. The change of care workers, however carefully done, may then be experienced as a devastating rejection. This could precipitate a spiral of violent, and desperately self-destructive behaviour. There are occasions when a child can become so relentlessly destructive towards himself and other children as well as staff, that only literally 24 hour vigilance can stand a chance of limiting the damage. At these times staff are under enormous stress, due to the constant threat of violence. If these problems persist into the night and staff get broken nights sleep when on duty, they naturally also steadily become exhausted. In addition to this, the other children in their care are bound to be adversely affected, and badly frightened by the disintegrated child’s behaviour. The other children in the group are not only scared for their physical welfare, but also for their psychological welfare. Close contact with a child who is experienced to be out of control and falling apart, is deeply disturbing to well balanced adults. To children who are anyway having serious difficulties in growing up, there is a powerful fear that another child’s disintegration may tip their own very precarious inner balance. In other words, they fear that they too may fall apart.
In this situation the staff have a rapidly escalating problem on their hands. Disintegration is catching – and the staff are prone to it too. At times staff may feel anxious that they too could collapse like a house of cards. This is an extreme situation – but I am sure that there are few of us working in these settings who don’t feel this way at times. The child’s extreme anxieties can eventually threaten the integrity of their closest adults.
I have given another more detailed description of this process in a previous paper (Lanyado, 1988). The theme of disintegration and reintegration will be explored further on in this paper.
My next two examples illustrate Bion’s valuable insights into the way groups work. He describes the basic “work group” in which group members are able to co-operate and work towards a commonly shared goal, and contrasts this with three underlying group structures which constantly threaten to disrupt this achievement. These “Basic Assumption” groups, as he calls them, have been recognised in so many different group situations, that to me they seem universal. They are the Dependent Assumption group, the Fight/Flight Assumption group and the Pairing Assumption group. My examples are of the first two of these Assumption groups.
Example Three – The Fight/Flight Staff Group
If we return to our increasingly complex school event – let us imagine that the total staff group is now concerned about the effect of this one terribly disturbed child on the school. A staff meeting is called to discuss the problem. Ostensibly, this should be Bion’s “work group” working towards a common goal – containment of the child’s anxieties. In reality, something different is going on. The care group staff that are trying to contain the child, feel that they are under siege – both from the boy and from their colleagues. They are determined to see the situation through, to fight it, and not to give up on the child. Offers of help from other staff members only make them feel more incompetent, and are therefore difficult to accept. The good advice that their colleagues feel they are offering is heard as criticism. The care group which is under siege feels isolated from the rest of the school staff.
Those staff not involved with the child are partly relieved that this child is not directly their problem. They tried to help – but no one listened to them. They proceed to disassociate themselves from the whole issue, as if it was nothing to do with them. In this respect, they are in flight from the declared total staff group task, as they are no longer involved in the goal of containing the child’s anxieties within the school setting.
A resolution of this difficult meeting calls for the recognition of these underlying dynamics. They are experienced as very real emotions of anger, fear and loss by all the staff involved. Bion’s contribution is to draw attention to the underlying fantasy of the group, that the only way to cope with the problem is to fight it or flee form it. If these feelings and dynamics are not understood (and it is often very difficult in the midst of such meetings for this to happen) the meeting is likely to fail in its objectives, leaving staff dissatisfied and angry, and of course the child not helped. Sub-groups within the school culture may develop with opposing views on the issue, which are often not aired in full staff meetings, but fiercely debated outside them. A scapegoat may be sought as the source of the trouble. This can even help to unite the different factions for a while as the staff group come together to fight the common foe. Another possible outcome is that the whole group resorts to “flight”. In this instance, in addition to the rest of the school feeling the problem has nothing to do with them, the child’s care group staff may find ways of distancing themselves as much as possible from the problem – by becoming emotionally unavailable or possibly even by becoming ill.
The total “flight” dynamic may lead into another well recognised group structure which Bion describes – the Dependent Group. It is important to appreciate the fluidity that exists between these Basic Assumption groups. If the staff group takes “flight” from the conflict, there is often an underlying fantasy and wish that someone else will take over the responsibility for the problem. This is to some extent a destructive “dumping exercise”, but the underlying desperation of the manoeuvre should not be underestimated. In some situations a messianic leader may be sought to lead the staff group out of the morass they are in. This leader may be gratefully followed in his or her heyday, but they are in great trouble if they put a foot wrong – which they are bound to do in time. The staff group may then turn on the leader, making him or her into a scapegoat.
Example Four – The Dependent Staff Group
If we return to our hypothetical staff meeting, we might find that gradually a pressure is building up, on the headmaster – to “do” something about this awful child. Presumably he is expected to use some magical powers either to get the child to settle down again in the school, or to waft him away from it. If this is a headmaster who enjoys being masterful, he may well be tempted to step in as the ultimate authority and make some decision that takes all the responsibility off the shoulders of the staff. One of the risks he would take in doing this, is that he may get it wrong in some way or other, and will then have to carry the guilt and anger of the staff as a result. One cannot exactly scapegoat a headmaster – but life can certainly be made very uncomfortable for him by a hostile staff attitude. The problem in encouraging this type of dependency in staff is that it infantilises them and limits their creativity, encouraging the fantasy that the headmaster knows it all in some omniscient way, whilst the staff are basically ignorant.
A way out of this uncomfortable position for the headmaster is to refuse to take on this role, and insist that all staff continue to carry some joint responsibility for what goes on in the school. The tension generated by this inevitable prolonging of a distressing situation is likely to pay dividends in the long run – but will be extremely uncomfortable in the interim. I would think it is rarely possible to have every member of staff “united” as a group in this kind of situation. A majority consensus may well be the best that one can hope for – but this at least has the hope of paving the way towards working through difficult issues in the school and allowing reparative processes to heal the rifts that inevitably occur.
This leads me to a contrasting example. It is often the case, that whilst one part of an organisation appears to be crumbling, another part is busy getting on with very good work. I don’t actually believe that it is so despite the chaos that reigns elsewhere. I actually feel it may sometimes be because of the chaos that reigns elsewhere. At times complex organisations such as those we all work in, seem to be almost like living organisms. When one part of the organisation is under threat, another part may work extra hard to compensate for this. In psychoanalytic terms, this can be understood as the system’s attempt to repair itself through the process of reparation, and learning by experience. It is perfectly possible that in another part of the school system that is less directly involved with the disintegrating child, there are children who are felt to be very rewarding recipients of the staff’s efforts. What happens to them if they have a crisis? There was a striking example of this reparative process recently at the school where I work.
Example Five – Reparation and Learning by Experience
At a time of great staff stress for other reasons, a child’s father died, and he became understandably disorientated as well as somewhat bizarre in his behaviour. There were very difficult circumstances surrounding the death and staff were unsure about how to respond to the child. One of the most central concerns was that his mother had battered him in the past and he had only recently come off the NAI register. However the school social worker reported that mother was coping well under the circumstances and was able to help her son in his mourning. When he was due to go home for a weekend and knew he was in a broken down emotional state, this child suddenly panicked, becoming convinced that his mother would be unable to manage him and would batter him again. He communicated this panic to his teacher and care workers, who shared it with me. In the circumstances, swayed as we now were by the boy’s perception of his mother, we felt he couldn’t possibly go home. The social worker however knew that although these anxieties may have been justified in the past, they were not valid in the present. His mother was actually coping very well.
Because all the staff had been able to listen to each other (this had been initiated by listening to the child) we did not end up in conflict despite the fact that conflict was so much in the air in the rest of the school at the time. We actually listened extra hard to each other and acted as a well functioning work group. The social worker who had been about to take the boy home went to the mother without him, explaining her child’s fears. The mother wanted her son home and knew he needed her comfort and reassurance. The social worker and mother returned to the school to fetch the boy who could now see that his mother not only could, but actively wanted to help him. He had learnt a number of valuable lessons through this experience. His feelings had been understood by the staff who had responded appropriately. The staff had then carefully considered what would be best for him in the circumstances. He was aware that the problem of whether he should go home or stay at the school had been sensibly resolved by all the adults involved. He experienced adults working together for his welfare, as opposed to warring factions who all thought they knew best what was right for him.
I think this good outcome was partially the result of the staff motivation to learn from the stressful situations ongoing elsewhere in the school, and their unconscious wish to help the school to feel it could do good work with some of the children some of the time, if not all for all the children, all of the time.
In my description of these diverse staff situations there are four main themes I would like to emphasise:
- The child’s problem very rapidly becomes the adult’s problem which the staff network within the total system then has to deal with in order to help the child.
- One part of the total school system can be on the verge of disintegration whilst another part of the system is attempting to redress the homoeostatic balance by trying particularly hard to do reparative work.
- The need to work through staff conflicts is often lost in the constant pressure of the day to day work with the children and subsequently gets neglected.
We are more often guilty of the “sins of omission” than the “sins of commission” – by failing to let others know about feelings we have.
My first point is very evident from the examples given. The other three themes require some elaboration. The fact that staff can be under great stress when working with one child, yet still function well for another is illuminating. It is as if in some part of the school’s collective consciousness the fears of disintegration that we experience in one area of our work may actually spur us on to greater efforts to help another, more helpable child. It is an exact parallel to Dockar- Drysdale’s description of a child not always being able to offer direct reparation for, say, breaking a window, but displacing that reparation – by offering to help with the washing up. Whilst one part of the system appears to be disintegrating, another part may be re-integrating. This may well be an important life preserving process in a basically “healthy-enough” institution. I would argue that we keep these institutions “healthy-enough” by constantly attempting to remain as undefended as possible to the anxieties that are inherent in our particular institution’s work. For those of us who work in closed therapeutic systems, our (and our clients) most fundamental anxiety may well be the fear of disintegration. For this reason, we as a staff group have to remain constantly alert to the need to re-build – like the phoenix from the ashes.
In order to re-build we have to allow ourselves to become aware of the constant attacks which the integrity of the system is liable to, from the children and from ourselves. We cannot do this if we don’t talk to each other and listen to each other and ourselves, often enough. Too often it is what is not communicated that causes problems. I would also like to emphasise that some of the conflicts I have described, particularly if they remain unexpressed, can lie undigested and 10 of 11 potentially dangerously dormant in the school system. Somehow we all just want to forget about them, and always have ample justification for this in terms of consideration of other children’s needs. What are we to do? Are there further lessons we can learn, a few months later, over apparently “dead” issues? I think there often are, and that this is not just raking up the past unnecessarily, it is working through important conflicts.
Our current system of staff support and development
It has no doubt by now become clear, that for me, good systems of communication between staff, are essential if we are to do our work well, and survive. The problem is – we do not always want to hear what our colleagues have to say as it may upset us. It takes a long while – if indeed it is ever fully possible – to get to know each other well enough to frankly acknowledge our own mistakes. Maybe the best we can do is to keep striving towards openness with each other. There are many different ways of trying to establish this kind of culture within a school.
The school I am describing at present tries to do this through a series of staff meetings – some of them with the headmaster, some of them with myself. The teachers group, care staff group and total staff group, each meet weekly. In addition there are regular individual meeting times for all members of staff, plus smaller mixed group meetings. We do not however spend a lot of time “examining our navels” in these meetings! The shared focus of our work is primarily the child’s problem as opposed to the adult’s problem. As it is often the case that the child’s problem leads to problems for the adult, we will try to understand how the child is getting under the adult’s skin and what this means for the child. We do not, however, often find ourselves in the deep water of having to tackle an adult’s personal difficulties within a group setting, although on a one-to-one basis this may happen. This system of staff support is constantly open to change. I should also add that as someone with a central professional function of trying to support others in their work, I find myself enormously well supported by these meetings with my colleagues. As I am so much a part of the total system, my role is much more accurately described as a facilitator from within the system, than a consultant from without. I suspect that the headmaster’s role must inevitably be a lonelier one as it combines the need to consult and listen to staff, with the capacity to retain the ultimate authority within the school.
Another aspect of the staff support system is the importance of in-service training. The regular group meetings support our hearts but do not feed our heads! We need to educate ourselves and stimulate our thinking about the work. Reading and discussing relevant literature serves to keep us alert to different interpretations and understanding of the children which we may have previously been unaware of. Our present way of working is to have a study theme for a term which we approach in various ways. Guest speakers are invited as a part of a study day and we regularly read selected papers as a basis of discussion of the theme. Visits to other schools or hospitals working with children such as ours are also very useful and serve to remind us of the many different ways there are to tackle the same problems.
Earlier in this paper I said that I would return to the issue of reparation, as I feel it is central to our work in many ways. I would like to use this concept as a means of drawing this presentation to a close. It links our motivation for choosing this work, and the work itself, with whatever it is that keeps us doing it, despite the stress involved.
In its broadest sense, reparation means “making better”, literally repairing the damage, or allowing a healing process to take place. For many of us helping a child in need, finds an echo within us, when we identify that external child, with the way we ourselves were, at our unhappiest, when a child. We often couldn’t do much to help ourselves – but we can now, through helping the external child to get better. In this way we are not only attempting to prevent a child from becoming hopelessly engulfed by these pains, we are also symbolically helping the child within us. Reparation implies growth and integration – so just as we try to help the child, unwittingly the child may also help us. We call it job satisfaction, or talk about commitment but I feel that in some respects what we mean is that we do this work because it repairs and heals our own childhood experience. It helps us to feel better inside to be doing this job well – and by inference, we feel bad inside when we fear that we are failing.
If we struggle on alone, attempting to ignore or avoid our relationships with our colleagues, due to some of the discomforts involved, we will ultimately be self defeating. An organisational structure which formally encourages us to listen to each other more is not a luxury but a necessity, and one which I think we are all ultimately thankful for.
BALINT, M. (1957) The Doctor, The Patient & His Illness. London. Tavistock.
BION, W. R. (1961) Experiences in Groups. London. Tavistock.
DOCKAR-DRYSDALE, B. (1968) Therapy in child care. London. Longman Group Ltd.
FLETCHER, A. (1983) “Working in a Neonatal Intensive Care Unit”, Journal of Child Psychotherapy Vol 9 No 1.
KLEIN, N. (1937) “Love, Guilt & Reparation”, in The Writings of Melanie Klein, Vol 1 1980 Hogarth: London
LANYADO, M. (1988) “Working with Anxieties in a Primary Residential School”. Maladjustment and Therapeutic Education.Vol 6 No 1.
MENZIES-LYTH, I. (1981) “Social systems as a Defence Against Anxiety”. London. Tavistock Pamphlet.
SZUR, R., FREUD, W. E., ELKAN, J., EARNSHAW, A., BENDER, H. (1981) “Colloquium: Hospital care of the Newborn: Some Aspects of Personal Stress”. Journal of Child Psychotherapy, Vol 7, No 2.
WINNICOTT, D. W. (1947) “Residential Management for Difficult Children” in Deprivation & Delinquency, Eds. Clare Winnicott, Roy Shepherd & Madeleine Davis. London: Tavistock (1984).
Monica Lanyado was Principal Child Psychotherapist at Harmeny School and Course organising Tutor for Child and Adolescent Psychotherapy Training at the Scottish institute for Human Relations, Edinburgh, at the time of writing in 1987.