Working with the looked-after child and his network.
Published in “A Question of Technique. Independent Psychoanalytic Approaches with Children and Adolescents”. Edited by Monica Lanyado and Ann Horne (Routledge 2006)
This chapter draws on material from the therapy of children who come into the category of being ‘looked after’, placed in care settings through the intervention of the local authority. It address the challenge for the network of professionals who often hold the balance of power regarding the therapy. Part of the challenge for the therapist lies in determining what aspects of the therapy remain confidential and what need to be shared. This can create a tightrope situation. If she shares too much information too quickly, the therapist runs the risk of losing the cooperation of the child. On the other hand, she may also risk losing the child from therapy if she is seen by the network to be too withholding or too exclusive in terms of her relationship with the child.
The child may also be accustomed to an absence of confidentiality and express no concerns about this. He may be used to exposure – perhaps from lack of privacy in the network, perhaps from a perverse early experience. The child in this situation needs attunement and care on the part of the therapist, especially when sharing information is undertaken, as this has to be with the child’s informed knowledge and consent and not be part of a re-enactment of the past disclosure.
Psychotherapeutic work with a child in the care system is thus often wider and more complex than the relationship between therapist and patient. From the start, therapy happens in a context where several people are involved in the decision-making about the child’s current and future life. These may include social services teams, court representatives, foster carers and the organisations employing them. Some children continue to have regular contact with their birth families even in situations where neglect and abuse may have led to their removal. In her work with these children, the therapist’s dilemma is often about balancing the needs of the child in a context of the many competing external forces.
Whether in the care system or not, a child needs privacy, space and time to struggle with issues at his own pace. This work may be ‘out of synch’ with the timescale of the professionals involved. Often therapy is viewed as a quick fix for a child who may have had several broken placements, or be seen as a panacea for curing all the psychological problems of the child and of the system that is meant to support his development.
Professionals referring children for therapy often have specific ideas about what the therapy should address: for example raising self-esteem, reducing aggression, moving on from attachments to neglectful and abusive early relationships and forming new attachments. All will clearly be part of the remit of child psychotherapy; however, the process of achieving these goals will be affected in a number of ways. Nevertheless, the therapist first has to form a working alliance with the child. This may be defined as a basic willingness in the child to come and be involved with the therapist (Sandle et al.1980). It also involves a degree of basic trust and mutual interest between the therapist and the child. All the above are prerequisites for the forming of a therapeutic alliance and approaching the hoped-for goals of insight and understanding in the child regarding his problems.
How and whether these goals are achievable are important considerations, given that many of this population of ‘looked-after children’ have severe developmental delays and deficits due to the traumas they have experienced (Hurry1998). The term ‘developmental therapy’ evolved at the Anna Freud Centre as a specific way of working with such children. In her developmental role, as ‘developmental object’, the therapist is more evidently ‘herself’ and is (or needs to be) more spontaneous than in her interpretive role. These children often require the therapist to be creative, both in her timing and the techniques she employs. She may have to take a role in the play, to carry those externalised aspects of the child’s self that cannot yet be integrated, or to enact the role of feared or longed-for inner objects.
Writers such as Lanyado (2004) emphasise the non-interpretive aspects of the therapeutic relationship while others such as Stern speak of the ‘something more’ than interpretation that is needed (Stern et al.1998). This ‘something more’ is seen as a ‘shared implicit relationship’ which develops in the intersubjective environment between therapist and child. These authors draw on insight from parent-infant interactions and the ‘moments-of-meeting’ in which each partner recognises that there has been a ‘mutual fittedness’. Ann Freud was aware that developmental deficit called for help via relationships and that this help took precedence over revival of the past within the transference. She nevertheless drew attention to the fact that most children do not present a pure clinical picture and therefore require a range of therapeutic procedures. This view also allows for ‘selection’ by the child. By selection is meant that the child may also choose what to bring or to engage within the therapeutic arena.
The ‘looked after’ child in the therapeutic setting may not therefore comply with the wishes of the external professionals and carers in ‘telling’ the therapist about the problem. This can create problems for the network when the child’s behaviour either worsens or does not improve quickly enough. In situations like this, good inter-agency communication is essential.
Joan Hutton (1983) commented on the different ways that social workers and carers may conceive of therapy, i.e. as something to idealise or to be suspicious of, rivalrous rather than complementary. The author speaks about the benefit of ‘face-to-face’ experience between the therapist and the network. It means that the therapist, contrary to historical practice, may do the necessary work herself, dealing constantly with the split transference, and selecting those areas where either child and carers appear to respond to the dictates of the transference (i.e. they may both be acting out) or the child is arousing issues in the inner world of the carer or other members of the network.
When working with such deficit and deprivation, the therapist draws on her psychoanalytic understanding not only with the child, but in enabling the network to recognise their impact and presentation: an ability to trust, projection, over-activity, silence and other defensive behaviours will be discernible. Hoxter (1983), in an important chapter, writes of the complex nature of experience relating to children who have suffered deprivation. She notes that a capacity to process external events into internal experiences becomes central when considering what it means to come to terms with serve loss. This capacity, she considers, depends crucially on the opportunity to identify with carers who are themselves able to ‘feel and think’. The thinking, in Hoxter’s opinion, involves the capacity to bear experiencing the child’s feelings and one’s own accompanying feelings, until these have undergone a process of internal modulation, enabling the adult to make a response in keeping with what the child has communicated, rather than a reaction driven by the adult’s own emotions.
WORKING WITH THE CHILD IN THE NETWORK:
Jenny, aged 11, was removed from home because of neglect and abuse. In the first term of her therapy, Jenny’s way of communicating was largely through elaborate role plays in which she involved the therapist. Outside the sessions, the foster carers were being pushed to the limit by Jenny’s aggressive and sexualised behaviour. They thought that the therapist was being fooled by Jenny who presented as polite in her sessions. In her work, the therapist had to prepare to represent to the carers the interest of the child and her profound need for a protected space to struggle with her issues at her own pace and in her own way. However, she had to do this without isolating the carers or the network of professionals involved with the child. At a practical level it involved regular meetings with the foster carers. This offered the opportunity for the therapist to highlight aspects of the child’s behaviour that were rooted in the past relationships and which would need time to shift. Here the therapist is introducing the network to processes in the child which, though largely unconscious, continued to have an insidious influence on the behaviour and the child’s view of her object world.
Jenny’s carers were pleased when she started calling them mum and dad quite early on in the placement. They saw this as evidence that Jenny was settling and beginning to form attachments. However, Jenny’s history demonstrated a series of rapid yet shallow attachments that were easily dismissed when the placements ended. In her work with the carers, the therapist was careful to highlight the positive aspects in her attachment – that Jenny had not given up hope of a good relationship with caring parents. Here she was identifying an island of health in the behaviour. It was nevertheless important that the carers understood and helped Jenny to promote her own identity. First they needed to acknowledge the long list of separations and abrupt endings in Jenny’s life. Secondly, were these unresolved issues to remain ignored, they would continue to interfere with Jenny’s capacity to form meaningful and more profound attachments. The therapist’s work with Jenny continued alongside the work with the carers. In addition, the therapist encouraged the initiation of life-storey work to enable Jenny to begin the work of ordering and mourning her experiences.
Barrows (1996) writes that when the deprived children we treat can be enabled to develop a coherent sense of their own life stories, this should prove a way in to break the cycle of deprivation. Coherence, in Barrows’ opinion, depends on the interchange between internal and external reality, which in turn allows assimilating new experiences and ultimately a sense of hope.
Jenny’s early care had been highly tantalising and varied according to her mother’s state of mind about the people in her life. These mainly consisted of a series of brief relationships with men who were violent and aggressive. Jenny therefore had no consistency of care at a time in her life when the building blocks of a secure attachment should have been in place. Instead her relationships with others reflected the disorganised patterns written about by Ainsworth and her colleagues (Ainsworth et al. 1971). Jenny had been left to live in this unpredictable environment for the first nine years or so of her life, with brief respite in the care system. This meant that by the time she was placed on a full care order at the age of 10, many of these ways of relating had become structured into her personality.
In her foster placement her behaviour veered from being perfect to exploding in spectacular temper outbursts, which were often accompanied by violence to others. She would then expect things to carry on as if the outburst had not happened. She showed little remorse, and seemed not to have any idea of the impact of her behaviour on the other. In working with Jenny, her therapist had first to join in with the role play and yet stay sufficiently outside these activities to retain her observing and reflective stance. This was not easy as Jenny could become totally immersed in the games and at times could be much dissociated from the real situation in the room. Nevertheless all these roles, though elaborate, meant something to the child. For example, the therapist had to endure being shut out of the room, threatened by security guards and imprisoned. Often she would have been set up by Jenny who, as the social worker in her play, seduced the therapist (mother) into thinking she would have her child returned. Jenny’s play was symbolic in that it touched on many aspects of her history and longings. Nevertheless the therapist had to be mindful of the situation outside the therapy room and the potential it had to break the placement.
Meetings between the carers and the therapist helped to lesson their guilt that they were letting Jenny down; they thought, for example, that they were not ‘good enough’ parents and were relieved to find an arena to think of this in the context of Jenny’s projections into her objects. Such meetings also offered encouragement and support for their attempts to set manageable boundaries and expectations about behaviour at home. A further consultation with the school enabled the teachers to stick with Jenny and to find ways of keeping her in school (thus not re-enacting her early experience of being sent away) while protecting others from her violence. Here the reliability of the others involved as well as the sensitivity of the therapist to the external situation was critical in protecting the child’s treatment. In addition, understanding how the network can be driven to re-enact the internal world of the traumatised or acting out child. (Davies 1996) was vital in this work.
When these systems of communications work well, the therapist can be a key person in decisions about the child’s current and future needs. For instance, she will be appropriately placed to inform the network about the child’s state of mind and relationship to objects both internal and external. In situations where this involves a change in placement, the therapist would be in a unique position to advise about the child’s level of preparedness and the level of support needed after a move.
This does not mean that Jenny’s treatment was plain sailing, even with this flexible and supportive framework. Many adjustments had to be made to technique as Jenny continued to act out her wishes and distress. This put her safety in jeopardy: when following a very involved role play, Jenny ran down the street screaming and laughing hysterically about being put in prison. The carers, who had been waiting for her, were not amused as Jenny ran into the busy road, seemingly unaware of the danger to herself. The adjustment to technique was that the therapist then left plenty of time at the end of the session to re-establish herself and regain touch with the reality of the situation. With Jenny’s permission, the therapist also affected a handover to the parents, passing her into their physical care and giving verbally a brief sense of what Jenny might be struggling with as she left the session.
Jenny was able to continue and make progress in her therapy because of this flexibility in the therapeutic approach. At times she opted to involve her carers actively in the therapy by insisting that they come in for part or all of the session. They were bemused at this but gradually began to see that, as Jenny gained trust in the therapeutic situation, she began to show through her actions and behaviours in the room something of her real conflicts. It is not easy for a therapist to work in this way. Nevertheless the capacity to make some of her thinking transparent, and to be observed as she struggles and sometimes makes a fool of herself in the process, can ultimately work to the benefit of all concerned.
A SECOND CHANCE FOR EMMA:
KEEPING DEVELOPMENTAL ISSUES IN MIND
Emma was referred for psychotherapy at age 6 ‘to be made “adoptable”’. She had been previously adopted at age 4 but after 6 months was returned to the care system with the label of being unlovable. Emma faced the difficulties in her development, described by Jill Hodges (1982) in relation to adopted children, of coming to terms with being born to and relinquished by her birth parents. Emma had to face this dilemma not just once but twice, when her adopted parents also gave her up. After 18 months in once-weekly therapy, Emma was adopted again, this time successfully.
Emma’s play in the first six months of therapy reflected a high level of preoccupation with dirt and a frantic effort to scrub things clean. The sink was the main area of play for much of that time. Emma would demand more and more washing up liquid or cleaning material. However much she scrubbed the sink and the dishes, they were never clean in her eyes. Repeated scrubbing began to take its toll on Emma’s skin. Externally, I was able to supply a large plastic apron to protect her clothes, but had to bide my time before Emma was able to listen to my interpretation about feeling hopeless and unworthy. Emma then attempted to scrub me and I became concerned about damage to my skin. I began to see as an attempt to externalise onto me, her black therapist, and her feelings of unworthiness. In one painful session, I was invited to close my eyes. When I opened them Emma had painted the white doll black. The doll was pushed roughly in my arms and tears were visible in Emma’s eyes as I tenderly wrapped the naked doll in a paper towel blanket.
In this play there were obvious questions about who Emma could be in relation to me. Did she have to become like me to be accepted by me? It was therefore important that I did not reject the baby, who I believe represented Emma’s fantasies about her earlier relationship, first with her birth mother and later adoptive family.
During the second six months of treatment, more of the real Emma came into the room. Her behaviour became challenging: for example she would jump on the chairs and invite me to stop her. Emma was demonstrating her need to be held, but her behaviour also invited reprimand. When I verbalised this, her mood changed and she became the small child who wanted a mummy to tuck her up in her cot. This baby also fooled the mother into thinking she had gone to sleep but when the mother had fallen asleep the baby would sneak out of the door. Could I be an attentive mother? Could she merit such a mother? I struggled to interpret this play and my counter-transference feelings were that I should be vigilant.
I spent a lot of time commenting on the part of Emma that longed for a mummy who kept her eyes on the baby so that she did not come to harm. It was equally important but more difficult to link this to the baby Emma who grew up expecting to be punished and who pushed until it happened. This led to Emma recalling angry confrontations with her adoptive mother and the painful memory of father not intervening to rescue her from her mother’s anger. Emma then began to speculate that the same thing must have happened when she was with her first parents. As the therapy entered its tenth month, Emma came to the conclusion that she had been given the wrong parents. Although this in some respects could be interpreted as a defence against the pain of rejection, it was also the beginning of a shift in Emma’s thinking that she was not totally responsible for her abandonment by two sets of parents and it was vitally important not simply to focus on the defence at this point.
It was now possible for Emma to begin to fantasise about having the right kind of parents. The right kind of parents in Emma’s mind consisted of a father that would spoil her and a mother who did lots of cooking. In drawing her ideal family, Emma was clear that they would have a skin colour similar to hers rather than the brown skin of the therapist. Emma nevertheless needed the therapist’s permission and good wishes to have such a family. She had reached this point because she had been able to make an attachment to her therapist and to form some identification. In the context of this relationship, she had begun the task of knowing who she was and what she wanted.
From the start of Emma’s therapy, her therapist had to work with an extended network of carers and professionals as well as attend to Emma’s struggles to make sense of her experience. For the network, the therapist had to represent Emma’s wish to take her ‘second chance’. This meant engaging actively with the network to shift their position of extreme caution. Emma’s social worker had been anxious about moving too soon towards a second adoption. Here the ghost of the earlier failed attempt was rearing its head. In saying that Emma was ready, the therapist drew heavily on Emma’s material, which now showed that she was prepared and able to take the risk. The following are excerpts from a therapy report written at the time:
Emma is as prepared for a move to adoption as she is likely to be but needs the permission of the adults to get on with her life and the forming of new attachments. I expect Emma’s move from her present carers to be painful for both her and them. However it is essential that she does not have to feel the responsibility for the carers’ pain as well as her own, or feel she has to hold back from taking the plunge into a new life. It is nevertheless vitally important that Emma keeps in touch with these important attachment figures in her current life.
The right kind of parents
The search for an adoptive family for Emma began in earnest after this. After the family was found, the therapist continued to occupy a vital role vis-à-vis the foster carers and the adopted parents during the transition from one home to another. As with Lanyado’s patient, ultimately the transition was made easier by the therapist’s continuing involvement at this time of change (Lanyado 2004:ch.6). Further, Emma was greatly supported by her social worker who had been with her throughout her time in care. In this respect Emma was lucky in that there was a constant person who knew all about her and her history, offered continuity and was committed to seeing her settled and happy.
When Emma heard that an adoptive family had been found, she was immediately concerned that her therapy would end. The therapist confirmed that their work together would be continuing while Emma settled into her new life. Relieved, Emma announced that she would paint a picture. She started by mixing colour, grey, black and white. She considered the result for a moment and then added a splash of red. Emma stirred this and said, ‘Now we are the same, the colour of strawberry milk shake’. The therapist picked up on Emma’s wish that she could be her mummy instead. Emma agreed. She brightened, however, when the therapist said that they could talk about Emma’s wishes about her newly identified mummy.
Emma hoped she would have brown hair and hazel eyes like her. She should not be too tall; otherwise Emma would not be able to reach to give her a hug. The therapist challenged the idea that the onus was on Emma to do the reaching. She said if might be even better to have a mummy who reached down to hug Emma. Emma liked this idea. She then began a new drawing of a house. It had a garden and a long path, which was dotted with black spots. The spots represented the therapist walking up the path to see her. The caption was: ‘This is the house I would live in.’ It was signed to her therapist with love from Emma. She then returned to a play seen earlier in the therapy when the baby would climb out of the cot when the mummy was not looking. Here Emma could agree with the therapist’s comment that she was very anxious about what lay ahead for her.
Over the next few sessions, Emma began to bring dreams about her birth mother. In her dream her mother had dark hair and wore lots of rings. She did not recognise Emma when they met. Emma seemed very sad. This dream seemed to indicate that a process of mourning had begun for the lost mother of Emma’s early childhood. Mixed into this was also an anxiety that her therapist might forget her. Emma needed to remember consciously and to mourn this painful period in her life. I believe this enabled her to take the risk of making an attachment to her therapist and ultimately to her new parents.
In the session after her first meeting with her new parents, her main concern was how to be with her foster carer and yet get to know her new mum at the same time. The conflict was about showing love to two sets of people. Are you going to make one set angry? This highlighted continuing feelings in Emma that the onus was still on her to make situations and relationships work. This concern was passed on to the social worker who had further work to do with the foster carer to ease Emma’s transition to her new family. Emma clearly had enough of her own conflicts to struggle with as the following extract shows. It follows her first overnight stay with her new carers:
On the journey in the car Emma was anxious to stay completely awake. She wanted to fix her own seatbelt. She described waking very early the first morning and lying in bed cuddling her teddy. ‘I was waiting for someone to tell me what to do.’ At breakfast she said she felt so hungry, but it didn’t matter what she ate, she could not get full.
The attempts to be self-sufficient showed both her difficulty with trust and her defences against possible disappointments. They also replayed Emma’s desperate sense, under stress, that she had to make things work. Later she was afraid that she would get things wrong. Emma did not think she could knock on her parents’ door to say she was awake. Her overeating was a further sign of anxiety (it had been evident earlier when the first adoptive placement broke down).
The first six months in an adoptive home is very difficult. Emma pushed her mother to the absolute limit. She began to have dreams that she was handed back to Social Services. Emma refused to let her new mother do personal things like comb her hair. She would come from school to her sessions with holes in her new tights and clothes. She kept falling off her bike and was covered in bruises. In the sessions Emma deliberately played up to me and was often cruel and denigrating to her new mother, yet she insisted that her mother came in for part of the session. Gradually the situation began to shift. I watched Emma’s painful attempts to get close to her mother by playing with her hair, by touching, sniffing and licking her. This was difficult for her mother but she impressed me with the capacity to tolerate it. In this respect Emma was like a small baby discovering the smells and sounds and tastes of Mother for the first time. In another way she was taking a chance in showing her own imperfect, damaged, unworthy bits.
Emma began to find her place with her new family, which meant that some rejection of me was inevitable. Her play at that time was mainly about her new family – a white mummy and daddy, sitting together, watching the children play. The parents in the play were anxious to ensure that the children were well strapped in on the swings. Emma was beginning to take a chance on owning her new family and relinquishing the stance whereby she had to be responsible for her own care and safety.
Several factors helped to make this adoption successful. The parents told Emma that they would keep her no matter what. Gradually, Emma gave her parents permission to tell me some of the things she forgot to bring to her sessions, for example when she had been naughty at home. I had to tread a difficult line at times as Emma used me in a manipulative way to undermine her mother’s attempts to set limits. I was nevertheless impressed by the tenacity of these new parents. They brought Emma reliably to sessions in all weathers, travelling many miles in the process. They joined an organisation for adopting families. They tried desperately hard to maintain links with the foster carers who, sadly, had been unable not to attempt to undermine the adoption efforts and who were now stepping back from the arranged contact.
Essentially one of the major differences in favour of this adoption working was that Emma continued to have her space in therapy to struggle and puzzle, regress and move forward. Externally she had been lucky with her parents who have used all the supports available to them to love this child who was once designated ‘unlovable.’
THE IMPACT OF ADOLESCENCE ON CHILD, CARER AND THERAPIST
Jonathan at 13 was referred for a psychotherapy assessment. He was on a full care order and had been living with his carers for 19 months. At home he had become surly, withdrawn and uncommunicative. When challenged he became angry and complained that his carers did not understand him.
Jonathan came into care when teachers informed Social Services about his high rate of absence from school. On investigation it came to light that his single mother had been mentally unwell for some time. Her illness had built up gradually through Jonathan’s early life and over time he had assumed the role of carer, both for himself and his mother.
Jonathan’s first year as a ‘looked-after child’ was fine in that he seemed to thrive on having a father and mother who looked after him and allowed him to be a child. This suggested that some of his early dependant, developmental needs had been met before his mother became ill. The concerns about his behaviour seemed to coincide with the onset of adolescence. Jonathan still craved the attention of his carers, particularly his foster father, but his behaviour sent out contradictory messages (I need you, but do not get too close). The carers struggled unsuccessfully to negotiate a comfortable level of contact with Jonathan, resulting in severe strain on the placement.
Hoxter (1964) states that the specific features which differentiates the adolescent from people of other ages is, of course, the experience of puberty. Much of the adolescent’s behaviour in the community may be seen as an external expression of the unconscious anxieties and conflicts aroused by pubertal sexual development. Furthermore some of the community’s reaction to the adolescent expresses the anxiety of the adults when faced with this. Other key tasks faced by the adolescent include becoming more responsible for the self, modifying the reliance on parental ego-support, turning more to relationships and identifications with the peer group. These are generally considered amongst the normative tasks of adolescence. However, for children like Jonathan, with unsatisfactory early relationships negotiating these tasks present additional challenges to both the child and the carers. The capacity to help and guide these troubles adolescents presupposes some working through of the carers’ own adolescent conflicts. In conducting Jonathan’s assessment, which also included interviews with the carers, the therapist found this not to be the case.
His carers had little difficulty with the little boy Jonathan who wanted to cling and was content for decisions such as what he ate and wore to be made for him. The young man who had become concerned about his image and who worried about his masculinity presented a different kind of challenge. It meant that the carers had to find new ways of discussing and sharing information with him, accessing advice and providing sympathetic support without alienating or patronising the young person whom he had become.
Tonnesmann views the environmental provision as one of the crucial factors in helping the adolescent to have his ‘second chance’ to master and integrate conflicting aspects of his development. If this is ‘not good enough’, the author cautions that this second chance is likely to fail (Tonnesmann1980). Failure in this context could be adolescent arrest, or foreclosure – a rigid defence structure – with premature pseudo-adaptation to adulthood.
In assessing Jonathan, it was clear that he had the capacity to use psychotherapy and was motivated to accept help. This suggested that there were sufficient intra-psychic organisation and ego resources to engage with the therapeutic process. Jonathan’s fear in coming to therapy was that the therapist would be stern and silent and would consider him to be mad. The transference could already be seen to be in operation – a common fear for adolescents experiencing the dramatic changes and challenges of puberty but, for Jonathan, perhaps also involving feared identification with his mother and projection on to the therapist. The capacity to form a transference relationship was important as it allowed for the possibility of Jonathan revisiting and re-working his infantile ties to his mother, one of the necessary tasks of adolescence.
The issue of time to work through these issues, in addition, had to be weighed against the current distress in the placement. In recommending therapy for Jonathan, the therapist was also concerned that some work would be needed with the carers, prior to or alongside the work with Jonathan. In a clinic setting this would have been done by another therapist experienced in helping parents/carers to think about the impact of the child’s development on them. There was no one immediately available and it fell to the child’s therapist to fill the breach. Aware of the risks in such work – perhaps more normal with a younger child – the therapist also recognised that in working with the system in this way, she was ideally placed to assess the carers’ capacity to shift their position, to appreciate the complexities of adolescent development and to adapt their care accordingly.
At the start, the therapist was interested in learning something of the carer’s own individual attachment histories. In doing, this, she was engaging them in thinking and reflecting on their pasts and what might have been left unresolved – and therefore be acted out – in their relationship with Jonathan.
Jonathan’s carers had come to fostering with good ideas about offering troubled youngsters a better experience of parenting. However, they had been totally unprepared for the resurgence of their own adolescent conflicts. Because these had not been resolved, the carers had no strategies for helping Jonathan to manage his. There were six meetings, at the end of which the carers felt sufficiently encouraged to go on and seek their own individual therapy. Both had suffered traumatic early experiences and had thought they had put these firmly behind them until Jonathan came along and began to ‘press their buttons’.
The role of the foster carer
The foster carers’ task, once considered so natural as to require little in the way of training or special expertise, has had to be re-evaluated because of the complex needs of the children in their charge today. The book Companion to Foster Care gives extensive information on what is now required to care for this group of children:
Foster carers require training in child development generally and attachment theory in particular. They should have an understanding of how the various unfortunate experiences that most of the children they care for will have undergone have affected their development and they should have some knowledge of how best to help them recover. They need to have techniques available to help them to assist the young person in building trust and self-esteem. In addition to training, foster carers need to be professionally supported in order to meet the need of their charges.
(Weal 1999: 3)
Child psychotherapists working with looked-after children can and do offer support to carers. This extends beyond their physical management of the child to thinking and understanding the processes of re-enactment that occur in systems around distressed and disturbed children. The psychotherapist thus holds a key position in helping the network to think about its impact on the child and vice versa. However, there are many pitfalls in this way of working. Splits and polarisations can occur, not just between child and carers but between the carer and the different organisations they work for. The therapist therefore treads a careful line. She has to maintain the therapeutic alliance with the child, promote the good things in the placement and at the same time highlight the areas that need to change and the timescale in which this should be done in the interest of the child’s development.
In these three examples of therapeutic work with looked-after children one can see the adaptations of technique that are often necessary to reach such troubled and often traumatised children. This kind of adaptation is also discussed by Lanyado in Chapter 8 of this volume in relation to a late adopted patient. In all the cases mentioned the therapist also had to work actively with the network of professionals and carers without losing her central focus of her child patient.
With Jenny, her concreteness and alarming acting-out meant that the therapist had to be both sparse and careful with any interpretation she attempted. Containment and an openness to Jenny’s pain and confusion about her early life was necessary for most of the first six months of therapy. The work inside the therapy had also to be partly transported into the outside environment as the therapist needed to verbalise Jenny’s differing and confusing states of mind to her concerned carers. In this way the therapist often acted as a bridge between child and carers and in the process acted as a container for both.
In Emma’s case, it was the child’s creative way in engaging the therapist in work with her new adopted mother and Emma together that enabled a parenting partnership to develop – and the therapist’s capacity to respond with flexibility to the child’s creativity. Horne (2000), commenting on this approach, sees this as an important addition to a child psychotherapist’s way of working in that it does not impose artificial boundaries of what is therapy and what is parent work, but allows the therapist to retain the capacity to be responsive.
In Jonathan’s situation, the therapist had to acknowledge that therapy by itself would not move his development forward. The technique of working actively with both the adolescent and his carers was risky. The challenge for the therapist lay in her ability to maintain the adolescent’s confidentiality yet work with his ambivalence towards his carers and towards her in the transference. At the same time she had to be alert to the failures in the system and their ability to inhibit rather than promote the adolescent’s development.
Many of the children in the care system do not have the privilege of being able to grapple with their difficulties in a supportive environment. Many are subject to frequent changes, both of placement and social workers Often care plans for them are shelved or interrupted as each new worker tries to come to grips with their histories. Many of these children are left to drift. I agree with Hunter that therapeutic work with the child cannot take the place of a good care plan for the child. Rather it has to be an integral part of a package of care for the child (Hunter 2001). This package pays some attention to the external, but even in addressing the external environment it is predominantly geared towards the internal wishes and conflicts of the child and informed by a psychoanalytic understanding of these.
Ainsworth, M. D. S., Bell, S. M. V. and Stayton, D. J. (1971) ‘Individual differences in strange situation behaviour of one-year-olds’. In H. R. Schaffer (ed.), The origins of Human Social Relationships. London: Academic Press.
Barrows, P. (1996) ‘Individual psychotherapy for children in foster care: possibilities and limitations’ Clinical Child Psychology and Psychiatry 1(3): 385-97
Davies, R. (1996) The inter-disciplinary network and the internal world of the offender. In C. Cordess and M. Cox (eds), Forensic Psychotherapy: Crime, Psychodynamics and the Offender Patient, vol 2, Mainly Practice. London: Jessica Kingsley
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