We can all be therapeutic if we care to be : being therapeutic in the group living setting of a children’s home

Date Posted: Thursday, 21 May 2009

This piece is based on my notes for the opening session of the Caldicott College/ University of Greenwich/University of Exeter Post- Graduate Diploma course in Therapeutic Child Care which I led at Eagle House in Northwood from 1995 until about 2007. Although the course was in large measure underpinned by psychodynamic theory, it was not dogmatic about it and acknowledged the therapeutic potential of any consistently and sensitively provided care. The intention of the session was to extract the polarised qualities with which child care workers, social workers and other related professions seemed to imbue the word ‘therapeutic’. By this I mean that many people’s notion of ‘therapeutic’ was of something esoteric while for most of the others it was used as an ill-defined umbrella over any form of care which they were at that time intent on promoting! I don’t know if today’s reader will find that this piece has stood the test of time but to my mind it still has something to offer as a beginning to thinking about what it is to be ‘therapeutic’.

To avoid tedious repetition, I have used several words and terms which I intend as being understood as synonymous : for instance child, young person, children, young people, and also residential child care worker, care worker and staff. I have also referred to child as ‘he’ . This does not reflect any bias in myself but the reflects the fact that boys have tended to be the majority of residents of children’s homes.

We are all therapeutic if we care to be : being therapeutic in the group living setting of a children’s home

Defining ‘therapeutic’

The term ‘therapeutic care’ has been used to accommodate a wide spectrum of theory and practice in the caring professions. The word ‘therapeutic’ has on the one hand been viewed as that which is only understood by psychiatrists and psychotherapists and on the other it has developed an undifferentiated, all-encompassing quality when, for instance, it is used as an adjective in front of the term ‘children’s home’. Given the difficulties we face in being specific about this elusive word, it may be useful for us to have a working and hopefully uncontentious meaning. In a recent personal survey of dictionary definitions the word ‘healing’ seemed to be the one which all the various sources I explored agreed upon as being central to the notion of ‘therapeutic’. For our purposes, I propose that we can accept ‘therapeutic’ as an equivalent to ‘healing’ as long as it is understood that ‘healing’, in so far as it relates to a group living setting for children and young people, refers – though not exclusively – to the healing of emotional wounds rather than physical ones.

How do we make a child’s experience a therapeutic one ?

Residential child care workers in a children’s home who feel comfortable taking ownership of this definition of the word ‘therapeutic’, will have faced themselves with the question in relation to the care they provide, “How are we able to make a child’s experience at this children home a therapeutic one ?”
In beginning to answer this question, it is my view that residential child care workers should firstly accept that the emotional difficulties experienced by the children they work with have their source in the past as well as the present. How children are when they first come to live in the home is a consequence of what has happened to them in their earlier childhood. Care workers should also be in accord about desiring to create an environment which can accommodate and engage children who are in a state of high anxiety. In whatever way this anxiety is expressed, a child, when first arriving at the home, is feeling uncertain and unsure. If a children’s home is to be therapeutic, it should provide a welcome which encourages and helps the child feel safe.
A safe environment is in large part made manifest to the child by the physical surroundings of the home and this includes not only the child’s initial visual experience of the exterior and interior of the home but also how much he can identify with the home’s social and cultural climate. The most engaging and emotionally containing attribute of a safe environment for a child in a therapeutic setting is the quality of the relationships established by the staff in their day-to-day interaction with the children.

Primary therapeutic work : using ritual and routine to build up trusting relationships

Primary therapeutic work in a children’s home is carried out by staff using the every day routines, rituals and activities of the group living setting as instruments for both engaging young people, and through time, developing relationships with them. For the young people the predictability of rituals and routine involved in getting up, going to bed, preparing and eating meals together, and sharing in activities can all help them begin to feel safe and begin to trust their environment. From the security of this base unhappy children can learn to trust other people and more importantly feel safe to build a relationship with caring adult parenting figures. These relationships are the most powerful means of promoting personal change and growth. The reliable and consistent provision of good experiences is the foundation of an effective therapeutic approach to caring. All this is easier said than done. Staff must work hard and in unity to provide an environment where young people can feel safe. Children will test the boundaries of the environment to check how safe it really is. Staff must not only be tolerant of this but they should be prepared with caring and containing responses. Staff who react with inappropriate aggression or who emotionally or indeed physically take flight from this testing will only serve to confirm an unhappy child’s past experience of parenting adults as people who could not be trusted to offer sufficient nurture.
In the group living setting of a children’s home a necessary component of the staff’s care as they seek to contain, engage and help children to grow, is the giving of intense attention to the unique individual needs of each child. It is vital that every child in a children’s home knows that at all times he is valued positively and kept in mind by all the adults responsible for his care and especially by those who have particular responsibility in caring for him from day to day. It is imperative that each child is encouraged and enabled to make healthy, stable emotional relationships with adult figures. It is only in this way that the children will begin to able to trust the wider world. This enabling encouragement requires staff exercising exceptional sensitivity, insight and prolonged determination.

The importance of the group

A children’s home offers young people a group living experience and the group should be used therapeutically as a microcosm of the much larger group of people which makes up the wider community. Members of a group are attracted to each other, enjoy each other’s company, congregate together, unite in activity and learn from each other , and, when cohesion is inevitably threatened, can help each other solve individual and group problems. Yet just as each individual in the home has boundaries so should the group. In order to foster individual growth, imagination and socially based self-determination, these boundaries should be defined and contained neither by the imposition of regimented power which cannot be questioned, nor by a laissez faire attitude, but by staff who are confident in engaging the group in a way which is sensitive to the group dynamic while respecting the needs of each individual in the group.

Working cooperatively with other significant adults

Placing a child in a children’s home is not an isolated action. It is invariably a fundamental part of an overall care plan which has been devised after consultation with the child by significant adults in his life. Offering uninterrupted individual care directed towards a child’s healthy growth is likely to meet, directly or indirectly, his emotional, social and educational needs but only if this is provided by taking due cognizance of the wider aspects of his whole life. The care provided for a child in a children’s home should dovetail with the overall care plan. Any caring strategies used must be focused on the reasons why the child has been placed in the children’s home and they should not merely be reactions to his current symptomatic behaviours. Although isolation from distracting and unhelpful dynamics may be helpful in the early stages of a child’s placement at a children’s home, care cannot be therapeutic if it is provided solely in isolation from the wider community.
Managing the therapeutic environment

Those charged with managing a therapeutic children’s home must have the resilience to withstand the pressures which will be placed upon them. Such pressures are built up through the expectations which are held of them by the children, the staff, their line managers, the local community, and various local authority agencies and national bodies which register and inspect them. These pressures are inescapable in a children’s home where young people with intense emotional anxieties are brought together. If they are to maintain the resilience they need, managers must have a well-informed, sophisticated insight of the problems experienced by the children. This level of awareness is essential if the members of staff are to be supported to understand both the meaning of their work and to cope with the anxieties their work inevitably throws up for them.
The managers of a children’s home have also to be concerned with the tensions created by the home’s relationship with the local and wider community. Conflict often arises because the wider community has little understanding of the purpose and culture of a children’s home. Managers also have to have an understanding of what is often called ‘the real world’ and they have a responsibility to reach and manage a tolerable balance at the point of engagement between the children’s home and the local community. Without breaching the bounds of privacy and confidentiality managers in children’s homes and indeed their line managers have a responsibility to educate the wider community about the work of children’ homes and this is part of the therapeutic task. It calls for exceptional diplomatic skills.

The significance of realistic expectations : things often get worse before they get better

A children’s home which puts all the elements described in this article in place has made a start towards becoming ‘therapeutic’. I have not prescribed any distinct theoretical approach but I have implied that a staff team with a unified, humane, adult, sensitive, and tolerant approach towards the care of children is likely to be therapeutic not only in relation to the children’s experience but also to their own. Such an approach has been successful with young people when time has been allowed for all the stages of the therapeutic process to unfold. Once embarked upon the therapeutic care process is not one with obvious shortcuts. It is possible, and sometimes necessary, that the problematic symptoms of a young person placed at a children’s home escalate before the problems which lie behind the symptoms can be resolved. For those charged with the care of young people in a children’s home and indeed for those who are responsible for placing them there, an all too easy yet devastating and demoralising trap to fall into is to have the expectation that there is an immediate correlation between the provision of a safe and accepting environment and an improvement in the anti-social symptoms of the underlying emotional problems which have led to a young person’s placement in a children’s home.

You can’t just talk good therapy

For staff at a children’s home talking about being ‘therapeutic’ or having a general sympathy with what might be described as ‘therapeutic principles’ is not good enough. Therapeutic care does not materialise out of this kind of thin air. Staff need a full understanding, and must be joint proprietors of the therapeutic vision, policy and practice of the home. This is effectively underpinned by staff who recognise the importance of the relationships they have between themselves, as ‘good enough parents’; relationships which demonstrate a facility to work together with a common understanding and purpose.
In summary, a children home’s capacity to be ‘therapeutic’ should be judged on the physical environment it provides, the primary care offered by its staff, the way the group setting is used to foster an individual’s healthy development, the understanding and insight of the staff towards the needs of the young people both as individuals and as members of the group, the shared vision and unified sense of purpose of the staff and those who manage them, and the effectiveness of the milieu thus created in promoting a better and more enriched future for all the young people.

Charles Sharpe 1995 ; revised 2009