Transitions

IFCO Presentation.

Introduction

During the course of our presentation we will be looking at transitions from different perspectives: ISP as an organisation in transition; the transitions that foster carers go through from the time they first think about fostering through to becoming skilled and experienced carers; children who come into foster care, often ill-equipped to cope with this transition and many others they may have to face, both large and small.

We think there is a link between them all. If an organisation can’t change, adapt and develop it will become dysfunctional and possibly die. It will also become a poor container for all the complex emotions that belong to the children, foster carers and staff. This in turn will be a poor role model for the children, as a well integrated and developing organisation is an important backdrop for the children’s own growth and development. We will be hearing about how foster carers embark on a journey of self-discovery and that this is also necessary if we are to encourage children to develop sufficient trust that they can begin to drop their defences and move forward.

I will start by talking about ISP, the organisation.

ISP AS AN ORGANISATION IN TRANSITION

ISP (Integrated Services Programme) was one of the first, if not the first Independent Fostering Provider (IFP) in the UK when it started in 1987. It was created by experienced foster carers who had been part of Kent County Council’s pioneering fostering scheme, for the most troubled and troublesome young people, which started in the 1970s. [Nancy Hazel, “A Bridge to Independence: The Kent Family Placement Project” Blackwells 1981]

Having been specially trained and provided with intensive support to work with young people with highly complex needs, who had previously been thought of as “unfosterable”, the carers who started ISP knew what was needed to make fostering work as an alternative to residential care.

It was an instant success. Foster carers were keen to join this new organisation. They were attracted by being treated as a professional, by the training and 24 hour support on offer and, of course, by the fact that they were paid well for this most difficult work. ISP also provided education for those children who couldn’t cope in mainstream schools. This was a big plus for carers because nothing puts a family placement under more strain than a child constantly at home without a school place. Children were provided with therapy within weeks rather than years of being placed. Transport to and from school or contact with the birth family; facilities for enabling contact with family members, all reduced the frustrations that many carers and children faced when dealing with a large bureaucracy.

When I joined ISP 6 years ago, as the Chief Executive, I brought with me a model of work learnt in a therapeutic community setting for severely traumatised children.

I began to see that much of what good foster carers do routinely on a day-to-day basis could be described as therapeutic childcare but was not realised or valued as such. I saw examples of children and young people, who had been expelled from group care in a residential context, starting to thrive in a family setting with more individualised care, without the pressures of group living with similarly disturbed children. This was turning on its head the received wisdom, that children needed specialist residential care after failing in families.

The model of therapeutic care that I had seen work at the Cotswold Community put the residential social worker at the heart of the therapeutic process. The reason for this being that children, who had severe attachment disorders, would not start trusting a whole range of professionals, but would first make an attachment to their focal carer. It would be to this person that the child would “open up”. Therefore, the residential workers needed to be specially trained and provided with on-going, expert consultant advice “to do the therapy”. Of course some children would need a skilled therapist in addition to this but this would be built on the bedrock of the main therapeutic relationship with the focal carer.

I felt that not only was therapeutic work already taking place in some foster families, but that by making it more explicit it could become a more conscious part of the treatment plan for each child. There are some children who are not ready to see a therapist for therapy. The foster carers though could benefit from a regular consultation with a therapist to help make sense of the child’s confusion and disturbance and the counter-transference feelings they were experiencing as carers. We have seen this develop within ISP during the last few years.

I joined forces with Jayne Westcott, who is Head of Operations, to run a training course in Therapeutic Childcare for ISP’s foster carers. Jayne had worked in a residential treatment programme in the USA for several years, so we had common experience to draw upon. Jayne presented this work to the IFCO conference in Argentina.

Jayne and I are very clear about the need for and merits of therapeutic care for young people whose past experiences and relationships with adults have created a legacy of pain or torture – emotional, physical and intellectual. We wished to present training for people in ISP which could provide an overview of Attachment Theory, acknowledge some commonly experienced behavioural problems, think about the importance of looking beyond the behaviour and, most importantly of all validate the many ways in which foster carers care therapeutically for children in the minutiae of every day living. We also wished to encourage and enable a “real” debate about the nature of the fostering task within ISP, the viability of transferring some “tools” or interventions from the “therapeutic community” setting to family life and to grapple with what is reasonable to ask of and expect from a family. Although we have numerous carers with no children of their own, or older children who have “flown their nest”, most have birth children of various ages still living at home and we must be mindful that all family members are involved in and touched by the experience of fostering.

A key premise is that for children with attachment disorders, it is the relationship between the child and the foster carer which will provide the arena for the work at hand. It will be essential to provide opportunities for the child to develop this primary attachment. This will provide the secure base for all of the “work” with the child and allow for that youngster’s progress and development.

In this sense, the rest of the “care team” – therapists, educationalist, social workers, psychiatrists, are really there to assist the carer, to help underpin the relationship between the child and the carer. This concept can be challenging for other professionals, as they may perceive a threat to their own status and “professional” worth. However, there is no disputing the fact that all children need a secure attachment in order to thrive.

The environment, in which ISP now works, is very different to the first few years of its existence. There is much more competition for the recruitment of new foster carers, both from other independent providers (there are now well of 150) and local authorities. Several local authorities are adopting a “treatment foster care” programme (following the Oregon model), and being encouraged to do so by the government, for the most difficult to place children.

Foster care is now highly regulated and every independent provider is inspected annually. Every new agency has to become registered before it can practice. It is still early days in the inspection and regulation process and there are still some anomalies in the system. Organisations like ISP, who are at the quality end of the market, should have benefited more than we have as a result of minimum standards being raised.

The stage that fostering is now going through reminds me of the evolutionary process I witnessed in therapeutic communities. The initial “missionary zeal” of the charismatic pioneers is replaced by an emphasis on policies, procedures and structures. The work seems generally more bureaucratic even if the basic ingredients, of what makes a good foster carer, don’t change much. Foster carers themselves have been pushing for more respect from fellow professionals and there are now more organised training schemes for carers than ever before.

However, there is a danger that we squeeze out the very qualities that inspire a family to foster. It is an incredible leap of faith to take an emotionally disturbed and traumatised child into your home and I think we are torn between wanting more and more people to do it and at the same time making the vetting process ever more complex.

Fostering in the UK has had a “helter skelter” journey during the last 20 years and I suspect the next 20 will be no less eventful.

TRANSITIONS: THE IMPORTANCE AND DIFFICULTY FOR CHILDREN

Transitions can be difficult for all of us under certain circumstances, eg, starting a new job, moving house, bereavement etc. Those of us who hopefully have strong emotional foundations to our personality will cope well with the more ordinary transitions of the day, eg, getting up, going to school/work, bedtime and sleep etc. We can move in and out of different situations and take different roles during the day without suffering acute anxiety, eg, being a husband, parent, manager, subordinate, one of a crowd etc. As a result it may be more difficult to appreciate just how difficult it is for an emotionally disturbed child to cope with transition. A small gap between situations can seem like the Grand Canyon. Transitions imply change or movement between. This is likely to cause panic for an emotionally unintegrated person. The panic will be a sense of falling forever between the gap. So, when we think about the therapeutic management of unintegrated children we have to give them extra special support, like stepping stones through the day, at key transitional times, eg, waking up, getting dressed, joining the group for breakfast, getting ready to go to school, the journey to school, all the movements in the school day (between classrooms, playtime etc), the journey home after school, arriving home, the evening meal, going to play, getting ready for bed, going to sleep, These are the obvious transitions in a day. There are many smaller ones. [Mark will be going into much more detail about these transitions in his presentation.] Once we understand how difficult it is for an unintegrated child to cope with transitions, it becomes a lot easier to find ways of giving support at the crucial times.

It seems to me that the difficulty in coping with transitions for the emotionally disturbed child has 2 main causes: firstly, emotional deprivation in the first few years of life, especially in the pre-verbal period; secondly, “multiple traumatic loss”.

1. Emotional deprivation and the reduced capacity to cope with transitions

The following passage gives a useful summary of the sense of wellbeing that develops during infancy when there has been “good enough parenting”.

“For the newborn only the actual presence of his mother (or committed regular care-giver) can provide the continuity, attention and sensuous pleasure needed to call up the infant’s rudimentary capacity to integrate his perceptions and set in motion the processes of mental development. When these needs are sufficiently met, and when the infant is able to make use of what is offered, this absolute dependence on an external person diminishes during the first year. The familiarity and pattern derived from a few dependable care-givers will have begun to develop into the infant’s sense of having pattern and continuity within himself: he will have a sense of being himself. His mother’s attention to him will have enabled him to develop a capacity to attend to what is going on and to be increasingly curious about it. From his experience of being thought about by his mother he will have become able to begin to reflect on his own experience. The legacy of his pleasure in being cared for seems to be found in his expectation of, and capacity for, enjoyment in an increasing range of relationships and activities which he is able to invest with meaning.”

It seems very clear to me that a child who has had this good-enough start to life will approach transitions in a fundamentally different way compared to a child who has been deprived of this emotional foundation. The latter has not achieved what Erikson called, “basic trust” and is in fact dominated by “basic mistrust”.

Contrast the above quotation with the following one from Sue Kegerris’ paper, “Getting better makes it worse”.

“Many children with emotional and behavioural difficulties can be understood as being caught up in a psychic state dominated by persecutory anxieties. By this I mean anxieties of such a primitive and basic nature that the children feel their very existence is under threat. This is in contrast to depressive anxieties caused by internal conflicts between loving and hating feelings. If persecutory anxieties predominate a child will tend to deny any bad parts of himself, projecting them into others and so experiencing himself as the victim of outside maltreatment. He has no sense of self-nurturing, internalised from a sustained sense of being nurtured. The idea of something stable and good, whether inside or outside himself, is constantly under threat and often quite absent. He may feel that his inner world is irretrievably in ruins, and may do his utmost to reduce his outside world to an equally devastated state.”

2. Multiple traumatic loss and the impact on coping with transitions

The key components of the ordinary mourning process are still viewed as being sadness, depression, numbing, searching for the lost loved one, yearning, anger, disorganisation, despair and eventually with gradual recovery, reorganisation. When this process has followed its natural path, the individual can also, paradoxically, be seen to have grown emotionally as a result of what they have been through.

By contrast, when mourning has not been able to follow its natural path there are likely to be many developmental regressions.

Many children who have lost contact with key attachment figures not through death, but through neglect, abuse or abandonment, are unable to mourn this loss. These children are unsupported in facing this loss by other attachment figures. It is less complicated to mourn the death of a loved one, than to cope with the ambivalence of knowing that a missed parent is alive and well and living a few miles away, but not wanting to see the child. For most children in care, the ordinary process of time that is needed to go through the usual process of mourning, has often also been filled with an accumulation of further losses and changes which it becomes almost impossible for the child to take on board. A great deal of the anger and loss of these children can be understood in terms of undigested experiences of loss. They suffer from “multiple traumatic loss”.

1. Their terrible experiences of loss become too readily lost when one is in direct contact with their disturbed and challenging behaviour.
2. Their losses aren’t ordinary and unavoidable. They are truly traumatic losses of the most important relationships in their vulnerable young lives. They are terribly alone and unprotected.
3. These traumatic losses have happened repeatedly without any real chance to recover from one loss before another loss takes place. It is difficult to retain an empathic attitude when these children become physically larger and more dangerous. It then becomes easy to forget what has led to this level of apparent detachment, hostility and violence.

As a result of early emotional deprivation, abuse (emotional, physical and sexual) and multiple traumatic loss a child will not have a coherent sense of self. He will be emotionally unintegrated. How does this link to a difficulty in coping with transition?

• He experiences panic (which often shown itself as rage) whenever there is a gap in provision, ie, whenever he is frustrated.
• He is driven to disrupt functioning groups because they are a threat and expose his own ability to function.
• He is drawn to “merge” with other disturbed children in excitable groupings to defend against separation anxieties.
• Shows little concern for others.
• No sense of guilt or ability to make reparation. He hasn’t reached the emotional stage of development of being able to see his primary caregivers as separate people with their own feelings and needs
• Generally restless and unable to concentrate or settle into any activity. This is linked to a need for immediate gratification and an inability to cope with frustration.
• He will have a poor sense of time and space. A day, a week, a month are difficult to understand. This is not about an intellectual ability to tell the time or read a calendar. It is more about an inner sense of time that babies acquire naturally through the process of being well looked after, ie, regular feeds, baths, nappy changes, bedtimes, etc
• An inability to play. Winnicott showed how a small child starts to creatively use the space between himself and his carer as he moves out of the total dependency of infancy. It implies a sense of security and trust which emotionally disturbed children have either yet to acquire or have lost.
• An inability to communicate feelings. Feelings are bottled up and explode into acting out behaviour.
• Uses “splitting” as a defence mechanism – carers, teachers, etc, are either all good or all bad, with little in-between. A “good” person can quickly become a “bad” person if causing frustration.
• Poor self-preservation, which can range from poor personal hygiene to self-harm. This seems to be linked to an absence of feeling loved in and for oneself rather than what one does or achieves, ie, the basis of a sense of self-worth.

These common characteristics of an emotionally disturbed child should convey why it is that transitions, or indeed change in general, will pose a threat and, therefore, explains the need for great care and attention to detail if change and transition is to be successfully navigated.

TRANSITIONAL OBJECTS

No description of how children need help to cope with transitions would be complete without saying something about the importance of transitional objects. The term transitional object was first used by D W Winnicott in 1951 when he presented a paper, “Transitional Objects and Transitional Phenomena”.

Transitional objects (or comforters as they are more commonly known) are a way by which children are helped to move from being completely dependent on, and almost identified with, their mother, to being a separate person, able to face and explore the rest of the world. All through a child’s development, his constant search for new experiences, his attempts to become more independent (“standing on their own two feet”), means giving up something that is already safe and familiar in order to explore strange and new things. It’s easier to explore new things and try new experiences if there is still some contact with the old and familiar.

These often rather smelly (smelly through frequent use) comforters fulfil this need. They are a symbol of a safe, happy familiarity. They are called transitional objects because they act as a transition from one sort of experience to the newer one, as a reminder of a safe time to which one can return in a crisis, or if one is sad or sleepy. As we get older and understand that the bond with mother (or primary carer) exists even when she is not around, such transitional objects gradually become less necessary. Having said that there has been some interesting work on how pets can become transitional objects for adults. Perhaps all of us have a favourite item of clothing that we like to wear as a comforter.

Research shows that attachment to a transitional object develops at around six months of age, when babies are beginning to recognise that they are separate individuals. Studies have shown that children who had a comforter with them in a new environment showed greater confidence and sociability than other children.

Sadly, emotionally disturbed children who, as I have already indicated, have had many changes of carer to contend with, have invariably had to do so without even the comfort that a transitional object can bring. This point is very well made by Monica Lanyado:-

“Where there has been severe emotional deprivation, many children will not have reached the point in their emotional development at which they are able to create their own special transitional phenomena. If they have been able to reach this point, this might in some measure help them to cope with ordinary, as well as more extreme, anxiety. Tragically, where there might have been a special blanket or other transitional object, it has often been lost as children in care move from one placement to another. With this in mind, the emergence of new transitional phenomena is an important sign that despite all the difficulties, these children are presenting some significant emotional recovery and development is taking place within the child. These are signs that foster and adoptive parents, as well as clinicians, should watch out for.”

John Whitwell
Managing Director
July 2005