As you may know, Jayne and I are working towards presenting a day’s training in Therapeutic Childcare, which will be first offered in March. In preparing for this I sometimes stumble across something that I haven’t read in a long time, which I remember made an impact when I first read it. One such is a booklet, “Routines, Limits and Anchor Points” by John Brown, who was the founder of Browndale, a Canadian childcare organisation, operating in the 1960’s and ‘70’s. It’s not rocket science but what Bettelheim called “common sense organised”. We are being asked to think about everyday activities from the perspective of the emotionally damaged child. This is the section on “Waking Up”.
Waking up can be a particularly difficult and painful process for emotionally disturbed children because their past experiences have not led them to expect anything good from the coming day.
The goal of the carer doing wake-up in a therapeutic setting is to create in the child a “readiness for engagement”. She should respect the child’s reluctance to engage and be sensitive and tactful in her approach. The atmosphere created at wake-up will set the prior conditioning for the kind of functioning the child will be able to attain during the day.
In her initial contact with the child, the carer should go quietly into the room, draw the curtains to let in the light and sounds of the day, tidy up any bedtime snack remnants.
She should not speak to the child unless the child speaks to her first. Through the change in the intensity of the light against the eyelids and the sounds of the carer moving quietly around the room, the idea is presented to the child that night is over and day has begun. He needs a little time to get used to the idea.
The next stage should be verbal contact. But talk should be generalities that don’t require an answer. She might tell the child it’s a sunny day, or it’s raining; remind him that it’s a school day, or it’s Saturday and some treat is in store.
Now the child has entered the transitory stage between waking and sleeping. He is conscious but not engaged. The next step is to encourage him to to tie in to the activities of the coming day. How the carer does this will depend on her relationship to and knowledge of the child. She might bring him a sliced orange, a cup of tea or chocolate, or a warm flannel to freshen his face; he might like to have his radio on; she might ask him what clothes he would like to wear today, or what he would like for breakfast.
The purpose of wake-up is to get the child out of bed in good shape.
This description is the polar opposite to the “stand by your bed” approach to getting up in the morning. The main message here is that the wake-up routine needs to be adapted to each child. Some might prefer the hail and hearty approach and some the softly, softly approach. If we don’t get this right through getting to know the child as an individual and what works for him, the day is likely to start “on the wrong foot” and, mixing metaphors terribly, from “the wrong side of the bed”.
As I was driving along in my car I heard a road safety expert being interviewed on the radio. He was making the point that although modern cars have many more safety features than say, 20 years ago, the roads aren’t any safer because people drive as if they are impregnable. He graphically made the point that if we really want to get people to drive more carefully, we should replace airbags with spikes! This made me squirm in my seat and reduce speed immediately! I went on to wonder about other examples where our preoccupation with safety has the opposite effect to the one we are trying to achieve. Is there a parallel to this with our emphasis on safe care?
Our cat Lennie is snow white and looks as though butter wouldn’t melt in his mouth. In fact he is a ruthless killer. Since Christmas he has caught about 20 rats and ceremoniously placed them on the doormat, in various states of dismemberment. I think he knows I have a strong aversion to rats and on one occasion brought back a live one, through the cat flap, and then let it go. We knew something was amiss when our spaniel, Rigby, joined in the chase. The rat (unnamed) somehow got under the dishwasher and up inside it. There was no way that I was going to go in for the kill so we had to tilt the dishwasher open the outside door and hope that sooner or later it would leave. I’m pleased to say it did some 12 hours later!
Last month I quoted from the booklet “Routines, Limits and Anchor Points” by John Brown. There is another piece on Leaving for school that I’d like to share.
“When a child is secure in a loving relationship with parents, a relationship in which the parent is invested deeply – but on an adult level – with the child, the child knows these things. He is secure in the unspoken knowledge that no matter where he is physically in relationship to the adult, the investment remains constant and secure.
But with an emotionally disturbed child who may never have had this relationship with an adult, separation from the caring adult is always equal to loss, and the separation must be preceded by certain anchoring devices that tie the child to the caring adult. This is done in a number of ways: with physical affection; by helping the child with his outdoor clothes, helping him find his gloves, the books he needs for school; by standing at the door or window to wave to the child as goes down the road.
It is important that the child going into the community takes with him a feeling of love, support and acceptance – not conflict and anxiety. He should not carry with him into the community preoccupations around problems of his relationship with the parenting person. He should be free to deal with the events he engages in, the people he meets during the course of the day. If the parenting person has done a proper launching job, she will have freed the child to operate at his optimum level when he goes out to function in the outside world.”
I get to sit in some very long meetings. Perhaps the longest is when I am a member of the Panel, which can meet for up to 5 hours. During the course of this I take every opportunity to get up and pace about to get the circulation going. While doing this I remembered having to do this on the flight to Singapore, one of the health tips to prevent deep vein thrombosis (DVT). I then went on to think about the flight socks I wear on long-haul flights and that perhaps we should issue Panel Socks, at panel meetings, to overcome the risk of DVT during interminable meetings! There is a marketing opportunity for someone here. Just remember it was my idea when you make your millions.
Jayne and I have now road tested our training, “An Introduction to Therapeutic Childcare”. We recently ran it for a group of relatively new carers. We weren’t as organised as we’d have liked to have been but we still got pretty good feedback. The basic message was that children whose emotional damage occurred during the pre-verbal period of infancy and early childhood are responsive to caring as a corrective, therapeutic experience. This has previously only been practiced in a planned way in a therapeutic community. We are exploring how it can be practiced in a family setting. I’d like to quote an extract, about play, from a book by Pamela Pick, “Children at Tree Tops”.
“Play is not a luxury to be restricted on all sides by things which are thought of as more important – the ‘musts’ of meal times and sleep and the ‘musts’ of the routines of the particular household. We found that keeping regular times for going to school, having meals and going to bed was necessary and that this framework created the secure background that we needed. But these routines were not beyond question and often less important than the shapeless, timeless, serious, unpredictable thing called play. “Playing is an experience, always a creative experience … … a basic form of living.” “… a creative experience taking up space and time, and intensely real.” “The playing child inhabits an area that cannot be easily left nor can it easily admit intrusions.” (Winnicott) It mattered, and we regarded play as a ‘basic form of living’. We did not think of it as a subject. It was life – it was serious – we did it.
I cannot catch the shapes and colours, the shadows and the wings of play in a net and describe them. Every family, every children’s home, every person has their own. Anyone coming to Tree Tops would find us ‘at play’ in the house, in the garden, everywhere. If he peeped into the garage workshop, he would see some boys hard at work, seriously busy with a model plane. Activities like these, pottery, gardening, music-making were always going on. He might nearly be knocked down as he walked up the steps to the garden, by someone rushing for ‘home’ in a game of hide-and-seek. Further up the garden he would hear shouts and yells from around the bonfire, where the children were warding off the smoke with weird shaped shields, used only a few hours before in battle elsewhere; some children were sitting astride a bundle of sticks as it was being pulled along to add to the other stacks of fuel; some were intent on getting out a large potato from those that were baking in the ashes. All fun and all seriousness was there. On the flat ground, our assistant and two or three of the children were playing cricket. … There was a different picture in winter. The workshop and garden still being part of it, but the playroom, conservatory, dining room, hall, study and kitchen then being the hub of much of our activity. The puppets, hanging upside-down must have waited for the time when the darker evenings drew the children indoors. The hollow sound of table tennis balls was heard; cigarette cards were flicked against a wall. Some boys were playing in the water tank. A visitor could be taken to the kitchen to survey a tray of jam tarts or come into the dining room and find a space among paint boxes and glue, to sit down and talk, or join a game of draughts.”
I couldn’t find a better description of a therapeutic culture. It conveys a general sense of well-being.
On a lighter note I came across this next item in the Independent.
“Heavenly Choices from Co-op Customers”
Some surprises in the Co-op’s list of the tunes most selected by bereaved families at funerals. Top is “Smoke Gets in your Eyes” (The Platters, 1959), second is “Another one bites the dust” (Queen 1980) and fifth, for some reason, is Wham’s “Wake me up before you Go-Go”. Even more puzzling is the number four: the old Wild West song “She’ll be coming round the mountain”.
It was strange to go to a part of the world over Easter (Singapore) where the preoccupation was the war on SARS rather than Saddam Hussein. We first noticed a difference on the flight, the fact that there were some vacant seats, which we have never seen before. We thought everyone would be wearing face masks in Singapore, but those that did were very much in the minority. I suppose one of the advantages of a dictatorship, is an ability to actually control what people do, e.g. I can’t imagine Tony Blair would have much success in trying to insist that parents should keep their children indoors for a fortnight, which is what happened in Singapore.
While based in Singapore we had a weekend on the Malaysian Island of Langkawi. There were 9 people (approximately a 150 seater plane) on the flight there, and we were a group of 5. I began to appreciate the disastrous effect SARS was having on the economy of the region.
I played golf with my son-in-law on the Datai Hotel’s golf course. A new experience for me was to see a family of monkeys charge across the fairway. This also gave me a new excuse for being put off when I hit a lousy golf shot. I think Alasdair and I broke the course record for losing the most golf balls. I fully expected to look into the trees and see monkeys juggling golf balls! We certainly didn’t go hunting for any balls we hit into the undergrowth. We were only too aware that the course was in the rain forest and that meant snakes!
In the middle of the night I was woken by the strangest sounds. I can only liken it to the cartoon character Daffy Duck. The next day I discovered it was the mating call of frogs. The most striking thing about being in a tropical rain forest, is the smell. It reminded me of vegetable soup.
This idyllic weekend was somewhat spoilt by the return journey to Singapore, normally only a 1½ hour flight away. Because there were so few people travelling the airline cancelled flights and re-routed us via Kuala Lumpur. This turned into a 9 hour return journey. The only redeeming feature was experiencing what must be 2 of the best airport terminals in the world, at Kuala Lumpur and Singapore.
You have probably noticed by now that I try to include an extract from a book or paper which relates to therapeutic childcare. I have a copy of an amazing paper by Barbara Dockar-Drysdale, written in 1953, “Some Aspects of Damage and Restitution”. I think it was her very first paper about the work of the Mulberry Bush, which would have been going for approximately 5 years by this time. You need to remember it was especially remarkable to be written in the post-war austerity years, when life was hard and things were scarce, so to be saying that it is appropriate to be tolerant about damage to property, would have taken some courage at that time.
“We must now consider varieties of damage which we encounter in the course of work at the Mulberry Bush, together with the types of restitution we have been able to observe.
First of all there are the children who smash windows, bottles and cups. There are 2 types of smashers; the child who screams in a tantrum ‘all right, I’ll smash a window’ and does so, and the child who smashes quietly and secretly. We had a boy at the Mulberry Bush who smashed a bottle nearly every day in a particular flowerbed. There are the ‘scoopers’ who scoop holes in plaster; in this group are often to be found the children who cannot make relationships – the ‘frozen children’. The true tearers are always girls; they tear their own clothes, sheets, counterpanes and so on: boys may tear, but usually with a particular end in view. Bed-breakers are another class; not all children vent their hostility on their beds, but certain younger boys tear beds, spring from spring, as it were. Destruction of educational material deserves a discussion to itself; the clean, tidy teacher and the dirty, untidy child, the clean, tidy textbook and the dirty, untidy exercise book have obvious connections.
Tearing of paper increases in the summer months, and the attack on walls and glass lessens. Plants may be pulled up, but not the plants which the children grow themselves. Branches are broken off trees, but this kind of destructive behaviour meets with disapproval from most of the children. It is perhaps worth mentioning the case of an enuretic who actually removed the rubber sheet in order to wet the bed. Tables and chairs seem to get broken through sheer hard use, rather than deliberate damage; cutlery may be burnt or buried – our losses in knives are extremely heavy. Pictures pasted on the walls are torn or defaced fairly soon, usually by small children. However, 3 posters of flowers remained on the walls for a year, and a row of posters depicting cheerful babies marching along, which was pasted on the wall beside the stairs, has never been damaged in any way during the same period.
Books are preserved astonishingly well by the older girls, but seem to fall to pieces in the hands of boys, and are the objects of savage attack by the very young (of both sexes) who tear them up and burn them. Fires lit by adults are put out by groups of younger children; their own fires, however, survive. Tins of fruit may be pierced with penknives, bags of flour are stabbed, and the inside of a loaf of bread may be scooped out. Eggs are smashed, hairbrushes, clothes and shoes are burned on bonfires; door handles are removed and locks are broken.
Psycho-dynamic principles provide the theoretical framework for therapeutic childcare and I have recently come across a useful description of the psycho-dynamic perspective by Ruth Schmidt Nevin.
“The psycho-dynamic approach sees all children’s behaviour as a communication to their parents (carers). When looked at in this way all their behaviour has meaning. Instead of seeing behaviour as a problem, parents (carers) can ask themselves “why this behaviour, now?” Behaviour is a reflection of a child’s development and emotional integration. Parents (carers) then have a key for helping children with their emotional lives.”
Clearly surface behaviour has to be managed but the ability to also stand back and think about what is going on and why is a crucial element in therapeutic childcare. Quite often I have heard people say everything is going well then suddenly out of the clear blue sky there was this huge explosion. Sadly sometimes these explosions lead to expulsion from school or the home.
In my experience there is usually a reason for the explosion but we may have failed to spot it or realise that something that appears small to us can trigger it.
“Research shows the earlier a child is exposed to extreme fear and not protected, the more likely it is that brain function becomes set to experience even mildly frightening events often only remotely associated with the original fearful situation as highly dangerous. Tiny triggers can then set off major fear responses, in particular rage, as a biological form of self protection of the child in the absence of a perceived caring and protective adult.” (Written by Monica Lanyado.)
This all sounds like wholesale destruction, but let us consider the other side of the picture. Not all the damage is done by all the children all the time; certain children do certain damage at certain times. Children who are recovering show great understanding of damaging behaviour of newcomers. The sum total is by no means disastrous, and we see to it that our equipment is either unbreakable or cheap and quickly replaced. What we have of value is kept out of harm’s way.
The spontaneous restitutive activities we have observed include the following. Children help with the housework (bed-making, sweeping and so on), they wash up, do laundry, wash floors or paint, distemper walls, paint woodwork, mend holes in plaster, repair beds, light fires, make cups of tea for grown-ups, give parties to other children, comfort and care for small ones and look after animals devotedly. They save up and spend money on parcels to send home to their families, make themselves very clean, decorate rooms, do jobs of all kinds for people from whom they have stolen (refusing to be paid), produce abnormally clean and tidy work in class, do carpentry (children have told me that wood used for carpentry is ‘a tree broken up’), make bowls of clay, etc., for presents to mothers, grow flowers and vegetables which they present to the staff, and buy or cook food for grown-ups (‘Here’s a cake for the gang’). It does not follow that a bed-mender emerges from a bed-breaker; although this is quite likely it is just as probable that he may be an ardent colour-washer. The girl who steals from me may not return the money, but she is quite likely to buy me a bunch of daffodils, and subsequently be able to speak of the theft and speculate as to its cause. These attitudes have proved perfectly acceptable to our domestic staff, who have the understanding which comes from human warmth and satisfactory experiences.
“Therapeutic Communities for Children and Young People” edited by Adrian Ward et al (Jessica Kingsley) has just been published. In it there is a chapter by Linnet McMahon, “Applying the therapeutic model in other settings”. Within this chapter there is a section “Holding the child in mind” which features a piece written by our very own Simon Peacock (Children’s Social Worker at ISP Watford”). I will quote this section in full.
“The Social Worker’s task involves providing emotional holding as well as practical services to children and families. Where children are in transition between birth families and substitute care, or in foster and adoptive placements, a social worker who can hold the child in mind, and demonstrate this to the child, often over a long period of time and through a number of life changes, can help the child in turn to become a container, able to think about rather than simply react to events. This is shown in Simon Peacock’s (l997) work with Bobbie.
Bobbie and her sisters suffered severe neglect in infancy and by the age of 10 Bobbie had experienced more than 20 moves of home and changes of carer. Their lives were presented to me in a huge cardboard box, equivalent to one full filing cabinet drawer for each child. This Pandora’s box created an unforgettable moment of emotional anxiety before I was able to get down to the task of piecing together Bobbie’s life story. I decided to call a meeting of the numerous professionals involved, at which all expressed anxiety to ‘do something now’. I felt, however, that in the first place the anxiety needed to be contained rather than immediately acted on. I would try to create some stability in Bobbie’s life, which in turn could begin to enable her to construct some meaning to it. Meanwhile, realising I would need someone to provide some containment for me, I sought supervision from a colleague.
Two years on I had achieved a more settled period for Bobbie in one placement and eventually, after another struggle with the organisation, obtained a placement for her in a residential special school offering a good holding environment, that is, a culture which could tolerate her aggressive and disruptive behaviour, providing containment not only through rules and boundaries but through a relationship for Bobbie with the teaching and care staff. However, her foster placement had to end and Bobbie’s belongings ended up in boxes in my house.
After a few weeks an excellent new foster placement was found. Things were looking up, except that I was told that the schools transport would not pick Bobbie up from the new foster home because ‘it was not in the contract’. The contract said to pick her up from Town A and take her to school but not from Town B where she was now, and which was a further 20 miles up the road. This meant I had to get up at 6am to pick her up at 7am every Monday morning to take her to Town A to meet the school taxi. I did the reverse journey on Friday evenings. Now I could quite easily have ordered a social services taxi to do the 20 miles from Town A to Town B and back – Parcel Force could probably do the job just as easily. What was important in this apparently minor piece of transport management was ‘a response to the actor and not the act’. (David Howe’s (l996) phrase). Bobbie needed a person who could carry her both literally and emotionally along the road from one part of her life to the next. I was making a tangible link for her and I was also making it with her.
The journey from school to foster placement mirrored the story of Bobbie’s life. The anxiety about whether the two cars would meet up in the right place at the right time on each journey went a long way in demonstrating my reliability to Bobbie. It also demonstrated that the disparate parts of her life could be held together in me and by me. I believe it also demonstrated that I was holding her in mind and not just the task of getting her to school.
Once the task of holding things together for Bobbie was seen to be done reliably then she could begin an attempt at containing painful and anxious feelings for herself. One day she told me that her favourite song was “All By Myself”. The realisation that the song had meaning for her was one of her first steps.”
This is a useful reminder to us all in ISP that transporting children is so much more than getting a child from A to B.
In mid October I spent a few days in Finland lecturing on the subject of therapeutic childcare. It is gratifying to go back to the same place as last year. Hopefully it means I impressed sufficiently the first time rather than they didn’t understand me and needed to try again. There were some familiar faces. It was great to meet Tapio, a Psychologist, who I met for the first time when I went to Finland 13 years ago. He inducted me into their sado-masochistic practices of the sauna, including the birch.
Pirjo Tuovila organised the main event, a 2 day conference on Advanced Therapeutic Child Care with approximately 140 delegates. This time I had to adjust to consecutive, rather than simultaneous translation. This had 2 great advantages. I only needed to speak for half the allotted time and during the pauses I could think about what I was going to say next. There were one or two moments when I felt panic during the pause because I wasn’t sure what I was going to say next but I don’t think anybody noticed. Pirjo and I shared the lectures and when she was lecturing the translator was whispering the translation in my left ear.
I am fascinated how something I say during a lecture resonates with people at a particular time and place depending on their preoccupations. I never know what it is going to be and it is usually not what I expect. This time it was bathrooms and toilets. Unbeknown to me, a group of staff I was talking to were in the middle of planning the re-design of their residential unit to work with mothers (with drug problems) and their children. So when I said that in my view bathrooms and toilets are the most important rooms within a house, this had quite a dramatic effect because it had not been in the thinking of the re-design of the building. I said that all rooms carry important symbolic messages which strike people instantly in the first few seconds. I also think entrances and corridors are important spaces we often neglect. Given that people are often at their most anxious during transitions, then these spaces can be thought about from that point of view. If bathrooms and toilets are designed for comfort, lingering and playing, then children receive the message that we have respect for their essential bodily functions rather than distaste and disgust. I was encouraged to think about this after reading Bruno Bettelheim’s book, “Home For The Heart”. Here is a short extract.
“It is common knowledge that too rigid an education concerning cleanliness can damage one’s personality. It is utterly destructive if the parents experience a child’s body and its products as disgusting. Nevertheless, most bathrooms, particularly those in institutions, are equipped in a way which shows concern only for the cleanliness of the place. Where they should convey an atmosphere of relaxed comfort they suggest distaste for elimination. It amazes me how even many psychoanalysts, whose patients spend uncounted hours and very large sums of money decrying their alienation from their own body and its functions, who suffer from how dirty they feel their body and its excreta are, provide only impersonal hygienic toilets for their patients, like those typically found in the office buildings where they practice. How can a patient believe deep down in his bowels that the analyst means it when he tells him he should accept and endure his bodily functions when, if the patient needs a toilet, the analyst’s is as cold and uninviting as was his mother’s toilet training. As long as psychoanalysts ignore these issues, how can we expect psychiatric institutions to be any better?”
It is extraordinary to see whole houses lit up in Sittingbourne, with Santas climbing up flashing ladders and then disappearing down chimneys with his boots in the air and a whole team of reindeer nonchalantly resting on the apex of the roof. How come we don’t have more electrical fires? My generation was brought up not to turn the TV back on until it cooled down for fear of causing a nuclear explosion! I reckon Sittingbourne can be seen from space at this time of the year. I return to sedate Gloucestershire at the weekend and in my village there might be a few discreet lights scattered over trees in front gardens.