Pirjo lives and works in Finland (Tampere). I first met her in the late 1990s when she visited the Cotswold Community among other therapeutic communities in England. Pirjo has, for several years, run an annual conference in Tampere. I have had the pleasure of presenting material at two of her conferences. Other contributors have been Paul Van Heeswyk, Richard Bowlby and Dan Hughes. This paper is an interesting example of her work. She has since become a fully qualified Theraplay therapist.
A Case Study: Using Regression in Foster Care
Pirjo Tuovila Licentiate in Psychology Specialist in Developmental and Educational Psychology.
In this case study I will try to shed light, by means of a concrete example, on ways in which foster care can integrate a child’s, in this case a girl’s, personality through healing experiences. It is essential for the child to be able to experience a deep emotional relationship that represents early care, which in her case has been insufficient or even damaging. The child is being truly cared for perhaps for the first time in her life or at least she can now experience the care in a new way. I hope the example will convey the significance of the different elements: the child’s ability to express her needs, the carer’s ability to empathise and meet the child’s needs, and the support provided for care as a whole by supervision and the professional team. As the story proceeds I will supplement it with the theoretical background introduced in the first part of this report. I believe this case study clearly demonstrates the typical background of foster children and their damaged experience of the world, both of which can be seen in the way they relate to themselves and the outside world.
The example comes from a home in an SOS children’s village where a couple – we can call them Maria and Tom – are the foster parents. The girl whose care we will be looking at can be called Lisa. She is ten years old and lives in the SOS children’s village where she is cared for by means of a special method, so-called cradle care, which makes use of regression.
I will first analyse three phases of Lisa’s life which have preceded her cradle care. Then I will describe the events that led the foster parents to implement cradle care systemically. Theory and practice will be presented side by side so that the readers can compare their own conclusions with the theoretical framework of the project.
From Birth to Age Five
Lisa is born as the third child in a family of several children. The eldest, who is about two years older than Lisa, is taken into care for the first time before she is one year old. This means that the problems in the family have begun a long time before Lisa’s birth and that during Lisa’s babyhood the care and the basic security provided by the parents have been insufficient and sporadic. More children are born after Lisa, which means that she has to learn to depend mainly on herself at a very early age. During the first five years of Lisa’s life all the children are taken into care several times and are then permitted to return home again. The family gets a lot of support from the community care system. When a crisis in the family becomes acute Lisa and her elder sister spend a lot of time at their grandmother’s. Later the elder sister has to be in psychiatric care for a long time; she has been battered by the father and, to some extent, sexually abused by another relative. The parents are violent towards each other and they drink heavily. The mother is mentally unstable and her behaviour is unpredictable. The father has a criminal background. The day care centre has very little significance in the lives of the children because the parents are unable to ensure that they get there. When Lisa is five years old the children are again taken into care and placed in a reception home.
On the basis of the above we can draw the following conclusions:
- The primary experience of babyhood, ie the experience of being nursed and cared for, has been damaged.
- This brings about serious disturbance in the bonding relationship. The child cannot fully trust and depend on the adult taking care of her. The ability to experience a safe and good regression phase is interfered with or the prerequisites for it are lacking.
- Because in this situation the child has no chance of attaining an experience of continuity and sameness, the integration of her personality is inevitably incomplete. She does not become her own “container” or an individual who is distinctly separate from her environment. The boundaries between self and the outside world remain unclear.
- With so many traumatic experiences, the good and bad experiences are not combined, leaving the child without a chance of creating an integrated image of self and the outside world. In a way, the experiences are not interconnected, but are often detached, unpredictable and disruptive. The child’s concept of self is incoherent.
- Lisa has become “an unintegrated child”.
From Age Five to Seven
Lisa and her siblings stay at the reception home for about a year. Experienced carers find it unusually arduous to take care of the siblings, whose behaviour is more complicated than that staff have ever experienced. When Lisa is six the children are placed in a home in the SOS children’s village. About six months after this new placement, the first foster mother leaves her job because of mental problems. Her way of raising the children and parenting them has been punitive. The result is therefore not surprising: in their interaction, the children behave in a very demanding, odd and even provocative manner. For the next six months there is a provisional foster mother in the home. The foster parents that the children have at present start their work when Lisa is seven years old.
In this phase of the story we see a very familiar phenomenon – the failure of foster care. Let us again summarise a few essential points concerning Lisa:
- She still cannot experience continuity in terms of her circumstances and adult carers.
- Thus she cannot form an emotional bonding relationship and true dependency on an adult.
- Consequently, the traumatic experiences recur.
- True recovery is not established even though there are definite signs of Lisa becoming attached to her provisional foster mother.
- Lisa’s personality is still very fragmented, which can be seen in her behaviour and relations with others.
First “Stable” Three-Year Period, from Age Seven to Ten
I have put the word “stable” in inverted commas. The external circumstances may be stable and rehabilitating – the place and foster parents are the same – but, as the story proceeds, the reader will notice that the stability is limited to the external circumstances. We can hardly talk about stability “content-wise” or stability as Lisa’s own experience. When I talk about Lisa’s school I do so mainly to help the reader get an idea of the passing of time.
The new foster parents, Maria and Tom, have started their work in the SOS children’s village. Lisa has to wait another year to start school, so that she will have time to mature both socially and skills-wise. Lisa has many personality traits characteristic of foster children. On the one hand, she has low selfesteem: for example, she is afraid she will not grow new teeth once she loses her milk teeth. On the other hand, she acts in an overly brisk manner, appearing like “a little mother”, and her siblings make fun of her because of this. Lisa has difficulties in making friends at the day care centre. Her ability to control her own behaviour is limited and she has uncontrolled fits of rage both at home and at the centre. When Lisa is having one of her fits her whole body arches backwards, which is a baby’s primitive way of defending herself against the feelings of breakdown and disintegration. The foster parents need to use physical holding to calm her down and to contain her. Physical containment precedes mental containment, and is in fact its prerequisite. Lisa’s contradictory attitude towards adults can be seen in that, on the one hand, she is afraid of adults and, on the other hand, she “hangs on” to them unselectively, seeking security and support for her actions. She often behaves aggressively towards her foster father Tom. Then again, she seems to seek contact and closeness. Tom needs to be skilful in handling her aggressive attacks, so that neither he nor Lisa will get hurt. The contact needs to last and continue so that it can, on Lisa’s part, develop in a healthier direction. Lisa’s way of expressing herself more by acting out than by verbalising is due to the fact that her ability to express herself verbally is insufficient and limited. Her sexual behaviour is very noticeable, as is the case with all the other siblings too.
Lisa starts school when she is eight. At first she openly confronts the teacher but then the situation calms down and the spring term goes well. During the first year in school Lisa begins to show more distinctly her affection towards her foster mother Maria, and she trustingly seeks to be close to her. New symbolic features also begin to emerge: the first animal character, a fox, appears when Lisa is at play. There is a mother fox, an idyll of a den and Lisa is one of the foxes. At one time Lisa says that Maria is the mother fox and that she herself is one of the cubs. In the next phase, her playing comes even closer to reality and she dares to be Maria’s baby. In this “baby phase”, in addition to holding Lisa in her lap, Maria gets to “swaddle” her and give her a dummy. It is noteworthy that many of Lisa’s sisters and brothers also want and are given dummies. The foster parents’ ability to care for the children and meet their needs in a profound way begins to show when the children are playing: the siblings often go under the kitchen table to build a hut and pretend to be babies. It is of immense importance that children have the ability to play. It is through playing that they process their experiences. At best, playing has an integrating and healing effect on the development of the child’s psyche.
When Lisa has a good chance of recovery, her biological mother petitions, for the first time, for the order to be reversed. This happens during Lisa’s first spring term at school. Lisa’s mother makes her intentions very clear to the children and talks to them about their coming back home with her. The parents are now divorced and the mother has a new boyfriend. The mother is, however, unable to keep her word about seeing the children: she agrees to meet them but fails to turn up time after time. When she does manage to come, the meetings have an atmosphere of blame and aggression. She cannot control her own behaviour or her words, and her conduct is unpredictable with adults as well as with her own children. Often drunk when phoning the foster home, she verbally abuses the foster parents and demands to speak to her children. This is why her phone calls are no longer accepted at the home, and communication by phone is more carefully controlled. Though manipulative and destructive, the mother can also be very persuasive. The children are in a very difficult and conflicted situation: they do not know what will happen in the future – they cannot settle in this home and in these relationships as the chance of being returned to their mother is looming in the background. The mother’s current situation and her mental instability make it impossible for the children to be returned to her – they cannot even spend their holidays with her. When a decision to continue the care order is finally made, the children’s situation is still not settled: the mother has severe mental problems and she manages to sabotage the care by bringing her own illness into the children’s daily life and by maintaining the threat that the care order will be reversed.
Lisa’s biological father does not demand a reversal of the care order. He is supportive of the children’s placement and realises it is the best thing for them. He is having one of his dry spells. The mother and her family have totally blackened the father’s character, and Lisa, for example, seems to believe it is her father’s fault that the children were taken into care in the first place. The 5 father tries to keep in contact with the children and the meetings are successful.
During this time Lisa’s mental state clearly deteriorates and she loses the stability she has already reached. She has a very low tolerance of failure and she does not get on with other children. She flies into rages for no apparent reason; she is often unable to establish contact with other people and she disturbs them with her behaviour. She has more and more trouble falling asleep and has nightmares. She is afraid that her mother will come and get her and the other children. Violent and destructive elements appear in the symbolic features which reflect the destructiveness of her world: her role is that of a helpless victim, both now and in her previous family life. At school, for example, Lisa pretends to be a wolf and attacks another girl. She sometimes crawls on the floor or hears heavenly voices which tell her to make trouble. Occasionally she pretends to be a crow and makes strange noises. She would like to be a dog, get a collar around her neck and live in a kennel. Her destructiveness takes on a concrete form when she tears her sheets, strangles her doll and bangs its head against the wall. She claims that her mother has done the same to her. At play Lisa’s activities lack all positive content, and she is unable to receive Maria’s care. Lisa undergoes psychological assessment and therapy planning. Her assessment results equal the level of a child of limited intelligence. It is decided that she will see a therapist twice a week from the beginning of her third year at school.
Before I deal with the summer period between Lisa’s second and third school year and with the actual cradle care which took place at the end of the year, I will summarise in theoretical terms the above two years:
- Lisa’s behaviour indicates problems typical of children whose mental development has been seriously damaged (that of unintegrated children). Sometimes she goes into a state of panic expressed by rage, which happens when she feels that her concept of self is becoming fragmented. Sometimes she acts disruptively and destructively in certain situations.
- The above-mentioned ways of expressing oneself, and especially the inability to express and control emotions, are typical of children whose early interactive or bonding relationship has been disturbed and who have a history of traumatic and violent experiences.
- Lisa’s behaviour clearly indicates her damaged way of relating to both children and adults. The way she relates to men in particular is very deviant.
- Lisa’s case clearly shows the great value of people outside the foster care: the biological parents in particular, their situation and ability to cooperate are highly important.
- Lisa’s healing process has a very good start and she establishes a real bonding relationship with Maria and a new kind of emotional reliance on her. It is an extremely traumatic experience for Lisa to discover that this new chance of recovery is destroyed by her mother.
- At the same time Lisa’s emerging potential for healing through regression in her relationship with Maria is suppressed. The same happens to the positive symbolic features already present in her play: the symbols become very destructive.
- Lisa’s unintegrated personality manifests itself as powerful, almost psychotic experiences and a desire to be something other than what she is.
- The “split” between different sides, the good and the bad in oneself and in others increases during the following summer, which I will examine in more detail in the following.
Late Summer Before Starting Cradle Care
Lisa’s biological mother has petitioned the authorities to reverse the care order for the second time. She is still unable to function in a contained way in relating to her children: she says and promises whatever comes to her mind, about reversing the care order, for example. The meetings, whenever she manages to attend them, are often quite chaotic. Lisa’s sense of reality or her ability to trust and believe her own perceptions and experiences is put to a severe test. This is also the case with her siblings. However, most of the summer goes relatively well.
Before beginning her third year at school, Lisa says she will not go to school. “I won’t go to school, I can’t do anything right, I’m nature’s child. I’m digging a wolf’s den in the woods. A wolf doesn’t need anything, I won’t come in and have dinner. I’ll eat in the woods.” For a week Lisa verbalises her unwillingness to go to school. What she says also expresses her fear of growing up. She is faced with a conflict: she cannot remain a small child, she has to grow up.
Lisa starts to have therapy sessions twice a week. Surprisingly enough, the therapist turns out to be rather undependable and does not keep to the agreed times for sessions. As no trust is built, the therapy is cancelled after a few sessions.
Around the time when the school year starts, Lisa and a younger child play with fire. They also break a window by throwing stones. These actions are concrete expressions of Lisa’s sense of inner destructiveness and of being destroyed. She heads for the woods on a rainy day with the same child, throwing away her glasses and her raincoat. This kind of behaviour points to similar experiences. Maria manages to stop the girls from leaving, which upsets Lisa completely, and she has a fit of rage. She screams that she is a wolf child separated from the wolf pack. She will go to the woods and live there. She recalls distressing memories of her mother and what her mother has said, and she said “I’ll take a knife and kill my mum”.
Lisa squirms, but Maria manages to pull her into her arms. Lisa screams: “Wolf children can’t be held, let go of me.” Maria assures her: “You’re a human child. Couldn’t you just be a human child and calm down.” Lisa says she cannot, because she does not have a dummy. Maria asks her if it would be all right if she fetched a dummy and a baby bottle and Lisa agrees. Afterwards Maria holds Lisa on her lap and feeds her with the baby bottle like an infant.
There is no sign of rage. While on Maria’s lap, Lisa talks about some of her memories and experiences, such as those from school, and how she feels that she cannot do things right there. She also tells Maria that she wants to be born again as a new baby, so she would not have to go to school. It says a lot about Maria’s competence that she asks Lisa to draw a picture of a baby, and together they discuss what the baby needs. Lisa’s baby needs reliable people. Grown-ups must not lose control. The baby would be taken good care of, she would be fed, she would be able to sleep and she would be held. The baby would not be left alone. Baby Lisa is afraid to grow up. She is scared of the bad person who hits her mother, herself or her siblings. Lisa says that a wolf’s life is easier than a human’s.
An interesting thing about Lisa’s drawing is that the baby looks like a little old woman holding a baby bottle. There is an object, possibly a rattle, on the floor at the bottom of the drawing, and two paintings on the wall: one depicts the head of a wolf and the other a baby’s dummy. In this way, she has managed to express a lot of her own experiences. The symbols that are important to her at the moment, the wolf and the baby’s things, are all present in the drawing.
That same evening, at her own initiative, Lisa writes a letter to her teacher. She writes something like the following:
I won’t be coming to school.
I’m a wolf child. Wolves don’t go to school. I can’t do anything right.
The letter is not sent to the teacher. Instead, Maria phones her and discusses Lisa’s situation with her. In Lisa’s own experience, she is both a baby and a wolf. These two very opposing sides, a needing and a destructive one, are on the surface. What is essential here is that, with Maria’s help, Lisa is able to grasp and re-identify very intensely the needing part of herself. She can also trust that her needs will be met and responded to. Lisa soon writes another letter to her teacher with the following content:
I’m a baby. I can’t read. I need a baby holiday.
I’ll be wearing nappies and sucking a dummy for a week.
This letter is sent to the teacher. During supervision the staff consider, from several points of view, how to respond to Lisa’s regressive needs, what can be done and, especially, what would best serve Lisa.
Cradle Care in the SOS Children’s Village
After various phases Lisa is now able to express many different sides of her personality, and in a sense she shows us the way. During the period described 8 above she clearly experienced psychotic phases, too, when the boundary between her inner world and the outside reality became blurred. Lisa’s inner disruptive force is stronger than the internal and external forces that contain her, and experientially she is closer to a wolf than to a human child.
When Lisa, a ten-year old third former, asks for a “baby holiday”, we must pause at the request, as it must be something very significant. We think it over and decide to give her a “baby holiday” from Thursday to Sunday. Lisa gets to skip school on Thursday and Friday; during these four days Maria begins systematic cradle care with her. Tom and others working at the home do their share to make it possible. We also agree that Maria will spend the morning with Lisa, giving cradle care, on the day when Lisa goes to school later than the other children.
Maria tells Lisa about the “baby holiday”, and in a way she is asking Lisa whether she would like to be a baby again for a while. Maria explains to Lisa that she can be a baby as agreed. It means that Lisa is not allowed to become “a full-time baby uncontrollably”, but only on certain conditions, which Maria will determine. This is called restricted regression, which gives the child the chance to go back experientially to a very early pre-linguistic stage of development, and to have healing experiences with an adult carer. Keeping to a certain plan is important with Lisa, too, as the danger exists that she will slip back into her own imaginary world.
In practice, cradle care begins with Maria and Lisa together turning an old laundry basket into a baby’s cot. Lisa is lying on this cot wearing a bib while Maria feeds her the specific baby food she has asked for and gives her warm milk from a bottle. Lisa even wants to wear her playsuit which she has outgrown a long time ago. Lisa is “happy, like a little nestling”. Maria reads her a story, but the story is soon replaced by Lisa’s desire to talk. She begins to talk to Maria about her memories and painful experiences.
After cradle care has started, Lisa spontaneously draws a picture of a wolf cub. The cub is howling and there is a teardrop falling from its eye. Lisa explains that it has been separated from the wolf pack and taken to live with good people, but it doesn’t yet know that they are good. Lisa is reaching for a very personal experience of her own in the picture and its story. It is noteworthy that, compared with the picture of a baby I described earlier, the wolf is skilfully drawn with its curved neck and tearful eye. The picture of the baby was very roughly drawn considering Lisa’s drawing skills. Later, in art therapy, Lisa continues to process her inner world and experiences through drawing and painting, which is clearly very beneficial for her.
Cradle care lasts 2.5-3 months, with sessions taking place once a week, though less frequently towards the end. After 8-10 therapy sessions Lisa says that she doesn’t need to be a baby any more. During the last sessions Lisa enters a new phase of development: she wants a certain kind of baby monkey. Maria has to look hard to find one that is exactly right. Lisa gives the toy monkey a name, here we can call it Violet. Lisa takes very intense and affectionate care of Violet, and takes it with her whenever possible.
Sometimes Lisa lets her sister look after it. At first Violet sleeps with Lisa in the same bed, later Violet sleeps in a cot next to Lisa’s bed and finally in a doll’s pram a little further away. Lisa reads stories to Violet aloud, because “otherwise she won’t hear, will she.” This remarkably improves Lisa’s reading skills.
For Lisa, Violet is a transitional object that comforts the child and gives a feeling of safety. With Maria, Lisa has a very deep personal experience of being nursed and cared for in an intensive emotional relationship with an adult carer. After this experience she can now start experimenting symbolically in a carer’s role herself when she is playing. She is clearly making progress. Also, her more developed playing indicates that her personality is becoming more integrated. The “co-operation” between Lisa and Violet is a lovely version of a good relationship between a mother and a baby: first they are inseparable, then the mother starts to wean the baby, little by little, but still continues to take good care of her. The experiences Lisa gets through playing are of great significance for her, because at play she can identify with both the baby herself, and she may become a mother later. With healing experiences of a new kind, she may not have to repeat her childhood story with her own children.
During cradle care Lisa makes remarkable progress: her outbreaks of rage disappear almost completely, her linguistic ability to express herself develops, as do her social skills, and her artistic talent begins to bloom. Lisa’s relationship with Tom and Maria now seems safe and trusting, and Lisa often shows this by hugging and kissing them. Lisa likes to go to school and her achievements are far better than those of a child of limited intelligence.
According to Maria, cradle care saved Lisa and gave Maria strength and faith in her own abilities. In the summer Maria herself is exhausted, she no longer sleeps well, and she has some panic attacks. It should be noted that this case study has only dealt with Lisa and her needs. In a large group of siblings, all the children have their own personal characteristics and manifest their needs and traumas in different ways. One of the children is in long-term psychiatric care and only spends holidays and some weekends in the foster home, while two are taken to therapy once or twice a week. This kind of situation is extremely demanding for the foster parents, both emotionally and physically.
I will now present some theoretical perspectives from this long story for the reader to reflect upon.
- Children often transfer their inner conflicts and experiences to their new relationships. The behaviour and emotional life of children placed in foster care often seem deviant.
- Because traumatic experiences are not remembered and cannot be expressed verbally, they are expressed symbolically in actions. When Lisa feels that a situation or an outside threat becomes unbearable to her, she escapes reality by going into her own psychotic world.
- The ego, self, personality – whatever we want to call it – of unintegrated children can only be reconstructed and integrated through actual positive experiences in an interactive relationship.
- By using regression and regressive elements, we can adjust to Lisa’s needs, and Lisa can have actual healing experiences in her relationship with Maria.
- Early traumas can be healed in a context and in an emotional state that are similar to the relationship between a mother and a child. This also provides the opportunity to experience something that has been inadequately or not at all experienced before.
- A healing experience in restricted regression includes the past, the present and the future.
- Powerful, shared emotional and physical pre-linguistic experiences make room for speech in a new way. The child can become her own container: after identifying her own feelings and experiences she can then begin to verbalise them.
- The significance of a transitional object is that it represents both self and the surrounding world. Thus Lisa’s toy monkey represents her own experience of being cared for as well as the foster parents’ ability to care for children. With the toy monkey Lisa can practice her own caring skills. It is an extremely integrating experience for a child to feel safe both at the giving and the receiving end, in playing as well as in real relationships. After all, that is what their later relationships will be at best: giving and receiving.
My goal in supervision is reflective consolidation of practice and theory. I hope this case study has helped the reader understand how practice and theory in the care of children are inter-related. I also hope that Lisa’s story will serve as an encouraging example of what can be achieved in foster care with skilful and brave foster parents. The main idea is to let the children disclose their traumas and hurtful feelings in their daily interaction and human relationships. Only in this way can they and their problems be truly understood and healed. This also implies that to succeed in their difficult task, foster parents need professional support and people they can share their experiences with.