Date Posted: Saturday, 22 December 2007

This essay review was first published in 2005 in Free Associations. It is published here by kind permission of the editor of Free Associations, Robert M.Young.

 

Residential Child Care Can Do With All The Help It Can Get

by Charles Sharpe

Essay Review of Therapeutic Communities for Children and Young People , edited by Adrian Ward, Kajetan Kasinski, Jane Pooley and Alan Worthington. London: Jessica Kingsley, 2003. Pp. 256. £18.95/$28.95.

 

I’ve just watched a fly on the wall television programme* about a children’s home which my wife recorded for me some months ago. Mention of this programme may be granted some relevance in a review of a book about therapeutic communities for children and young people, but my tardiness in watching a television programme has none, except that I have been involved in the work of children’s homes and residential schools for many years, and I still play an active role in offering consultancy and training to those working directly with children who are placed in residential care. Why did I resist watching this programme? Well, you’re probably there before me. I could not bear the pain it would arouse in me. I knew that the programme would not be about a children’s home which was a model of good practice, and I knew it wouldn’t illustrate what I believe is the typical children’s home in the United Kingdom: an imperfect, rather confused, but very human community, where the intent of those looking after the children is benevolent and where, when mistakes are made, adult hands are held up to accept responsibility, an accountability engendered by a wish to protect children. No, I knew the television programme would be about a children’s home where bad, abusive child care is rife. It would be a place in which children are doubly vulnerable as a consequence of their own personal predicament and of their exposure to the unsuitable staff in whose care they have been placed. This children’s home was not representative of the majority of children’s homes in the United Kingdom, but nonetheless what I saw going on inside it is a matter for public scrutiny and concern. Yet the kind of public exposé which this television programme represents tends to further demonise a much maligned service rather than engender any improvement in it.

Philip Stokoe, one of the contributing authors to Therapeutic Communities for Children and Young People, while specifically considering therapeutic communities, might also be writing about the entire residential child care provision, when he speaks of the pressures placed on a therapeutic community by the wider community and the expectations which the wider community place on such organisations, and in particular on those people who work directly with children and adolescents. He mentions the quite reasonable general anxiety about the threat paedophiles pose for children, yet this has led in turn to the quite unreasonable notion that anyone who chooses to work with children and adolescents is suspect (pp. 96-97).

I would accept that what stands for child care in most children’s homes is not good enough. This is not solely because staff in children’s homes are poorly trained. The cause is also situated in the underlying political and professional apathy towards the care of these children, and the lack of real public concern for them. Following this programme, thousands did not mass in the streets protesting about the quality of care offered to children looked after in the public child care system. They did out of concern for foxes, on the one hand, and, on the other, for the dogs that hunt them, but for these unfortunate children, no. The care of our most deprived children — those with the most complex emotional problems — is not of sufficient concern for us, despite the sensationalised and cheap indignation of the media.

At the same time those charged with national responsibility for overseeing the care of these children allow them to be looked after by staff who, though they have the best interests of the children at heart, are not trained to do the job. There is an expectation that staff will be trained up to a minimal standard in order to gain a National Vocational Qualification in the Care of Children and Young People (henceforth NVQ), but there is no requirement for them to have this qualification when they start to work in a children’s home. Mind you, the NVQ is not something to get too excited about. TOPSS, the UK national training body which is responsible for overseeing the training of social care staff, acknowledges that it is not a professional training but a form of assessment. Andrew Collie, who has long been involved in teaching residential child care staff and who is a contributor to this book, speaks of NVQ as ‘a competence assessed qualification with no training input requirements’, and though there are some knowledge requirements, ‘candidates are not required to understand anything’ (p. 241, Collie’s italics). It is a system, Collie argues, which because it has little or no quality assurance, makes it possible to provide staff with the minimally required qualification relatively cheaply. The concern here is that it is a qualifying system which denies the complexity of residential child care. It does not deal with the dynamics of the inner world or indeed with relationships and so does not equip the worker for the task. While social workers — like doctors, teachers and lawyers — are required to have graduate or post-graduate qualifications in order to practice, those working with children who have the most deep-seated and complex emotional problems are not. Viewing the singularly unsuited and ill-equipped residential child care staff in the television programme was tantamount to watching someone being pulled off the streets at random in order to carry out a complicated surgical operation.

Despite the perfunctory noises made for a few days following a television programme like this is, or indeed after a major investigation into a child abuse scandal, everything falls back into the old set. New procedures are introduced, new empires are built to service the procedures but the experience for the children remains the same.

That it is why it should be a time for three cheers when a book like Therapeutic Communities for Children and Young People comes along. Here is a comprehensive survey and depiction of good child care practice going on in residential therapeutic communities for young people. Considering in turn the ideas and origins of therapeutic work, its meaning, its practice, the management and development of staff, and the potential for its wider application in the future, Adrian Ward says he and his co-authors are writing about ‘planting hope and idealism in what feels like the most barren and poisoned of grounds’. They say they are not indulging in unrealistic idealism but are advocating the provision of a principled and disciplined striving towards promoting healthy change and maturity in the young people cared for in a therapeutic environment. My view is that they live up to the claim of planting hope and idealism, but, in large measure, they fail to explore why the ground is barren or indeed why it is poisoned. Two cheers and a half bottle of the Dom Perignon are called for, I fear.

The ideas and origins of the underlying theory upon which the book is premised are psychodynamic. In his introductory chapter Ward claims that he and the other contributors promote this as a theory base for their kind of residential child care — the therapeutic community — which is ‘used to understand staff dynamics and the management of relationships in the whole place, as well as to explicate the difficulties facing children and their families’ (p. 12). Ward owns that the therapeutic approach is one ‘of huge complexity and subtlety, which in practice has to be distilled down to a set of experiences which will make sense to these most troubled and difficult of young people’ (p. 11). Ward also includes the need for staff to make sense of these experiences. This is asking a lot of staff, and perhaps Ward might have explored further how this is achieved. He does not explain this in his introduction or in his later chapter. He avers without providing any substantiating evidence that staff in therapeutic communities ‘are normally well trained’ (p. 12). If as I understand by this that he means all staff and not just senior staff, then this needs some further clarification. My view is that insufficient consideration is given as to who is recruited to psychodynamic group work, what methods of recruitment are used to find these people and what is offered to induct them to the psychodynamic approach. If this whole process is not carried out thoroughly, staff inevitably fall at the first resistance to the care they offer.

In reality, whatever their potential, their experience and their qualifications, staff who enter any form of residential child care are seldom ready carry to out their responsibilities to the full when they start to work in children’s homes. Few and far between are the training courses — and Ward should know this since he has been responsible for leading one of the finest of these — which might provide them with sufficient intellectual and emotional insight to understand how a relationship is made with a young person whose childhood has not provided him with the equipment to develop a healthy relationship. Without this, the inexperienced worker struggling to engage with a troubled child is often left with feelings of having been defeated, of not being understood and almost invariably with a feeling that somehow the child is at fault. Such a worker may also find that those responsible for her management are all too ready to interpret her feelings of the hopelessness in her relationship with a child as a signal that she as a worker is not constitutionally, intellectually or emotionally up to the job. Yet the achievement of a healthy relationship between child and adult is a fundamental long term aim of the notion of ‘opportunity led work’ which Ward advocates as a working model for therapeutic residential child care.

Introducing the theoretical base of therapeutic communities for children and young people, Ward acknowledges the influence of Donald Winnicott and John Bowlby in informing the work of therapeutic communities. Bowlby is cited for his ideas about the significance of the quality of the relationships between children, mothers and fathers and of the consequences of early disruption in these relationships, and Winnicott for his developmental theories. Though they are referred to in later chapters by other authors, it is surprising for the introductory chapter of a volume concerned with therapeutic child care, that Barbara Dockar Drysdale’s (1990) work is not cited, in particular, her notions of the ‘frozen child’, ‘caretaker child’ and ‘archipelago child’. No mention either of Melanie Klein’s (1952) model of the development of an integrated child, or reference to Isabel Menzies Lyth’s seminal work on the defensive dynamics of institutions.

Ward offers a generic definition of group care as an approach to care which involves using a group of staff in a specific building, over a period time, to work closely with a group of people who need help. That residential child care is a group exercise seems obvious, yet the government body which is responsible for defining the purpose and setting the standards for children’s homes makes no mention in its literature about group living and how it may be used as a way of helping young people in children’s homes to resolve the problems which face them (DoH 2002) !

At the most recent count, there were about 6500 children and young people placed in residential child care in England and Wales. This care is provided by the public sector and the voluntary and private sector. Therapeutic communities, which are almost exclusively provided by the voluntary and private sectors, represent less than 5% of the overall residential child care provision (Department of Health 2005, Charterhouse Group 2005, Association of Therapeutic Communities 2005). It is unfortunate that Ward and his fellow authors, with perhaps the exception of Michael Maher, do not discuss at length or in any critical way how practice in therapeutic communities might usefully inform the work that goes on in the vast majority of children’s homes. Ward suggests therapeutic communities have a number of similarities with family centres, homes for the elderly, ‘drop-in centres’ and group living settings for people with learning difficulties, but he does not make any allusion to children’s homes (p. 23). It can seem that the authors, while content to preen themselves – justifiably – by recording their excellent child care practice, fail to acknowledge that most children in residential care are not provided with the quality of service the authors are describing.

Ward addresses one problem that faces the therapeutic community approach to child care which is shared by the entire spectrum of residential child care. He observes that ‘In today’s “evidence based” terms its effectiveness is still technically unproven, even though the best-known places of this sort have impressive track records of successful help to children and families stretching back well over fifty years’ (p. 13). The sceptical view taken of a psychodynamic approach by the political sphere and the politically influential scientific sphere has always been a barrier to those who promote psychodynamic work. In a social, economic and political world seduced by the spurious expedience of the fixed price ‘package’, and in the thrall of time limited cognitive and behaviourist approaches to problem solving, where specific scripts or actions are followed or taken with the claim that specific desired results will ensue, in a welfare environment in which problems of the troubled person are dealt with as part objects – for instance by ‘anger management’ – the holistic, time consuming psychodynamic approach is eschewed. This is not to dismiss cognitive or behaviourist approaches out of hand, but my own experience and that of colleagues I listen to suggest that the problems of many deeply troubled youngsters are not straightforward and are not always responsive to cognitive or behaviourist intervention.

When asking what therapeutic child care is and where it can be professionally situated Ward’s answer is that it is not social work. He may be right, though he does not acknowledge how enslaved residential child care is by the social work profession. Referrals to all residential child care resources, including therapeutic communities, are almost invariably made by local authority social services departments, and so residential resources are dependent on them for their income and are vulnerable to the changing professional and economic climate of these local authorities. This situation is exacerbated by a social work profession largely trained to view residential child care as a last resort for children and young people rather than a preferred option.

In his chapter ‘The Roots of the Work’, Kajetan Kasinski provides a short history of the development of child care in therapeutic communities, as well as defining, without being prescriptive, the characteristics of the children who might be helpfully placed in them. Children who combine the following characteristics: those who have an inability to tolerate family life which is associated with neglect, abuse and family disruption, who have a ‘case complexity as defined by factors such as duration of difficulties, range of needs and degree of multi-service involvement…associated with a high profile presentation and variety of “at risk” behaviours’, and who have an absence of resilience factors such as peer group support or the capacity to self-reflect, are, Kasinski claims, the children who may be best helped by a placement in therapeutic communities (p. 45). Yet these are characteristics which are shared by the majority of children who live in children’s homes.

Consequently Kasinski raises some ‘ifs’ for me which lead to a concluding question. If, as Kasinski argues, children with the needs he catalogues are being effectively nurtured in therapeutic communities, then there would appear to be a basis for proposing that all children’s homes should provide therapeutic care based on psychodynamic principles. If, as I would argue, the work of wider provision of residential care is based on false or at least confused premises, and if, as Kasinski argues, the therapeutic approach is effective, then would some form of fusion of the ways between mainstream provision and psychodynamically based provision improve the residential care of all our most troubled children? Kasinski in part admits to this possibility (p. 63), but it is not a matter that the other authors pursue.

Monica Lanyado’s chapter ‘The Roots of Mental Health : Emotional Development and the Caring Environment’ is important because it would provide an inexperienced residential child care worker with an understandable description of how relationships between a child and a parenting adult can go wrong, while offering an explanation of how healthy relationships might be made with a child who has not experienced a satisfactory attachment with a parenting figure. In summary, she observes that ‘the earlier the child is exposed to extreme fear from which it is not protected, the more likely it is to develop a brain function which becomes “set” to experience even mildly frightening events, often only remotely associated with the original fearful situation, as highly dangerous’ (p. 67). In trying to offset this development she argues that the therapeutic relationship attempts to create the healthy attachment which may have been dramatically interrupted or indeed never have been there for young people in residential care. This response is vital she argues, because we are now aware that the quality of attachment children have to their carers is crucial, since deprived and traumatised children are often trapped in an unhealthy attachment to their parents or carers which doesn’t promote healthy or physical development (p. 69).

The model of the therapeutic community which Lanyado espouses applies Winnicottian concepts of child development to the creative emotional growth of children in a specialised therapeutic environment. This is the model she says that Dockar Drysdale used, with additional thinking drawn from Menzies Lyth’s ideas about organisational defences against anxiety. It is based on an understanding of the relationship between the child and carer interwined with the impact the child has on the group of people around him and in turn its influence on him. As well as Winnicott’s concepts of emotional development, Bowlby’s attachment theory and the attempt to change the quality and strength of attachment relationships is the other important theoretical source for work in a therapeutic community (p. 76).

Citing Winnicott’s notion of ‘primary maternal preoccupation’, Bion’s description of the same state of mind as being one of ‘maternal reverie’ and Stern who describes the various attunements and mis-attunements which contribute to what goes on between parents and babies, Lanyado points out that ’emotional and physical development are natural processes which need a responsive and sensitive environment if they are to unfold in the manner which is closest to the true nature of the child’ (p. 66). She also indicates that the children who are the focus of the book, ‘have not had the benefit of such care for long enough’ (p. 66). Lanyado proposes that therapeutic communities, by their concentration on ‘providing carefully adapted environments to nurture severely deprived children and their families, are able to provide the specialised living environment that is required for some recovery to take place'(p. 66). According to Lanyado this demanding task is achieved by providing the children and their families with ‘intensive’ emotional caring, and that for children in therapeutic communities ‘attention to detail’ in their everyday lives is an essential aspect of their care (pp.66-67). Perhaps those youngsters in other children’s homes are due this attention to detail also.

Lanyado believes the experience of a therapeutic living environment can make the difference between a child who is closed off from forming relationships with adults who are desperate to love and care for him and a child who dares to try again to form a new relationship (p. 68). Of course all children’s homes have this potential but it does not become actual because there is a dearth of training in therapeutic methods for those who work in children’s homes.

In ‘Group Thinking’, Philip Stokoe emphasises that the purpose of setting up a therapeutic system is to create a structure which reduces the effect of the staff unconscious on the relationships between staff and child. He presses the importance of setting out the structures and methods of work explicitly, because when staff are pulled into some inner world enactment they are often involved in confronting others about their behaviour. This is very stressful and very frightening unless it can be done with reference to a previously agreed principle, but he claims that if this can be achieved the group can become the object of study in a therapeutic community, and a therapeutic process can begin in which the young person can witness his peers gaining insight and changing. The youngster then has direct experience of how with the help of staff (especially in the form of interpretations, which are descriptions of what seems to be going on in the young person’s unconscious), sense can be made of a peer’s difficulties, and finally, by joining in, a young person can discover and build upon his or her own ability to help and understand another human being (pp. 83-84 ).

Problems occur in most children’s homes because staff insight may not be accepted by the whole staff team, or may not be skilfully deployed, and so insight becomes undervalued, light is made of someone’s suffering and nothing is gained.

Stokoe points out how useful learning about projective identification is for the residential child care worker. He evidences the release this insight brings when the worker realises that she may not be totally incompetent, and the feelings that have made her feel incompetent are a consequence of an unconscious process in which those aspects of a young person’s experience which he might find unmanageable are lodged in her. He observes that Bion further illustrated this primitive process by showing how projective identification provided the baby with a form of communication by getting the mother to feel what the baby can’t manage, and so the mother can discover through thinking what is upsetting the baby (p. 85). In many children’s homes, of course, working at this feeling level can be problematic. Government guidelines and regulations – boundaries which have been set by an external agency – present a number of dilemmas for working at a feeling level. This is a problem which often occurs when an adolescent is in need of what in most families would be seen as healthy emotional support from a carer of the opposite sex. In the current climate of social care the prospect of achieving what might be emotionally right for the young person in such a situation lies somewhere in the space between having an outstandingly skilful residential child care team and Utopia.

Stokoe maintains that projective identification is the main language of the therapeutic community, and the children are continually filling staff and other children with those parts of themselves they are unable to handle. In considering the part played by transference, Stokoe concludes group work is such a powerful therapeutic tool because only aspects rather than the entire personality of a previous carer or sibling are experienced by the young person. Citing Tom Main, Stokoe talks of group transference in which a young person presented with a group of staff will create particular roles for them, so that each member of staff comes to represent a particular internal object. Thus one staff member may represent the good mother, while another represents the bad mother. Where a staff team has no idea of these unconscious processes, blame tends to be placed on to an individual member of staff. Where staff can think about these unconscious processes, they find them to be important sources of information (pp. 86-87).

Stokoe reminds the reader, as a number of the contributors to this book do, that working psychodynamically in a group care setting is complex. Being able to distinguish between when ‘therapy’ is going on or when the business of living is going on, requires fine insight. Some might argue that they are not always discrete, but here Stokoe argues that he is referring to the Kleinian concept of ‘splitting’. He suggests that staff have to recognise that the inner conflicts they experience here between their caring tolerance and what might be called common sense or getting real with the conscious world, is really a mirror of what is going on in the inner world of the young people. He suggests that staff build defence systems by necessity because the impact of the raw emotion is too powerful to cope with. Staff need to upgrade their defence systems – becoming able to tolerate uncertainty – and guard against falling back on what is known rather than to tolerate uncertainty. Here, as on a number of occasions while reading this book, I was reminded of Margot Waddell’s paper ‘Living in Two Worlds: Psychodynamic Theory and Social Work Practice’ in which she suggests that the social work model impels the worker always to ‘do’ something about a situation, while the therapeutic worker is concerned to allow space for things to ‘be’ in order that time is allowed for reflection and change (Waddell 1985, pp.89-90).

Proposing that even formal groups can become expressions of a defensive dynamic, Stokoe warns that the establishment of informal groups becomes a way to avoid work. For him, informal groups must be viewed with an element of concern and given careful consideration (p.94). This may appear to fly in the face of Adrian Ward’s affirmation of the value of opportunity led work in both his introduction to the book and in his chapter ‘Using Everyday Life : Opportunity Led Work’. Whereas Ward maintains that it is important for staff to be aware of the therapeutic potential of communication which arises out of everyday interactions, and that there are moments during daily informal engagement which stir up memories of earlier events and feelings that may allow the possibility of communication and insight, both Ward’s enthusiasm for informal work and Stokoe’s cautionary approach imply that staff must be insightful and skilful in how they exercise that insight. My personal view is that Ward does not sufficiently acknowledge or recognise the full therapeutic potential of ‘the life space interview’, Fritz Redl’s contribution to the ‘opportunity led’ approach to child care in a group setting (Redl, 1961). Ward seems to understand Redl’s approach more as a method of behaviour control than a therapeutic aid to encouraging healthy emotional development. Though he breaks down the processes of opportunity led work in a more digestible language than Redl, Ward gives me the impression that opportunity led work is crisis related and not so much about establishing healthy relationships (pp. 126- 130).

My own view is that if it is Stokoe’s proposition that formal communication in a group care setting for children should be the principal conduit of the therapeutic work, then he is taking up an intractable position. In essence it would be a denial of the social dynamic of the setting and a serious under-valuing of how healthy relationships may develop naturally. Of course, a healthy relationship between a young person and an adult charged with his care will not flourish if, as Stokoe argues, there is a denial of the difference between adults and children. It is this denial which has all too often led to the sexual abuse of children in residential care settings. He feels that this denial of difference is exercised, with political encouragement, in the development of the role of the mentor, or befriender in youth work. While criticising the superficial training these workers receive, he reinforces the importance of young people understanding that it is the adults who make the important decisions, and that therapeutic communities for children are hierarchical (p. 95).

In her chapter ‘The Contribution of Systemic Thinking and Practice’, Colette Richardson almost leaves the reader with no doubt that systems theory has been influential where there have been the resources available to apply it in the child care field. She comments that systemic thinking can be helpful in making deeper sense of some of the defensive dynamics of a group and its tendency to avoid the task for instance, in suggesting that it should be understood that an action which is experienced as negative may not originally have been intended as such. Contrarily, my view is that the systemic approach would lead towards task avoidance, and that aspects of the systems theory as described by Richardson appeared contradictory to the psychodynamic approach. This chapter is more about the conscious than the unconscious. For instance, one of the systemic biases which Richardson cites, ‘When people act they are normally trying to do something good’ (p. 104), does not rest easy with some psychodynamic theory, and here I am thinking mainly of Klein and Bion. Certainly the systemic approach she subscribes to might not seem to be as threatening to the inner world as the psychodynamic approach often feels to workers newly introduced to it.

Richardson defines systems theory as a framework for understanding complex phenomena. These phenomena, having the characteristic of being a whole with parts, and the whole is a part of a greater whole, are helpful if everything in the increasingly wider systems is harmoniously encompassing the smaller parts. The problem of systems theory in the field of residential child care is that for it to be effective the parts of each whole need an altruistic if not democratic dimension, and here the illegitimate use of hierarchy gets in the way. If one of the parts within a potential system carries more weight in terms of the exercise of real power, then at best only a faulty system exists. In the social work system which encompasses the social care system, seldom if ever does the residential child care worker hold power. I further argue when I consider the case of Emma and Edward later, that the residential child care worker doesn’t even get a vote. In fairness Richardson acknowledges this.

Despite the best of intentions, decisions will often be made in one part of the system without attention to the knock on effects for the other parts. Organisations therefore need mechanisms for keeping the systemic view, e.g., regular meetings where people can share the different effects of the different activities and decisions with each other (p. 109).

There are neither the resources nor the will to set up or to maintain such mechanisms.

In ‘The Meaning of Good Therapy’, Jenny Carter provides a fresh explication of the therapeutic milieu which has echoes of Bettelheim’s ‘A Home for the Heart’ (1974). Initially Carter focuses on the experience of food, mealtimes and what happens between children and their carers in therapeutic communities, which Adrian Ward in his chapter on opportunity led work omits to do. Ward’s tendency to limit the notion of opportunity led work to the management of negative ‘incidents’ ignores the possibilities for opportunity led work which are inherent in everyday occurrences such as mealtimes, getting up in the morning, bedtimes, sharing creative, recreational and domestic activities and tasks.

To an extent Carter compensates for Ward’s shortfall. Citing Bion’s notion of ‘reverie’ Carter argues that primary experience of being repeatedly lovingly fed, kept clean, warm and sheltered, helps infants develop the ability to think and to hold a concept of something good in their minds even when it is not there physically. In a children’s home, she argues, these experiences become a way of holding which recompenses children for early deprivation (pp. 134-135).

In observing that a baby ‘takes in more than milk at every feed’ (p. 136), Carter argues that for children for whom early experience has been a complicated and unpleasant battlefield, it soon becomes evident that coming together to eat food is an emotive area, and that it is through food that children communicate the range of emotions which are related to their early experiences, and in turn evoke emotions in those who are providing for them, of rejection and punishment. Carter makes the point that an understanding of the emotional content of feeding can aid the task of helping children accept food from adults. An adult’s understanding and empathy with the difficulties children may be trying to communicate rather than reacting with disgust, anger, rejection, or hurt will have positive consequences and will help children move towards more healthy and acceptable habits (pp.136-137).

Carter extends these notions to bath times and toilet times. Children may have areas of experience of these aspects of primary care which are associated with punishment, sexual abuse, a parent’s revulsion and disgust or a battle of wills. As a consequence they may hold distorted views of their body and what it means to others and this may effect their notion of themselves. Depending on their experiences these children may be muddled about faeces or about sex. They may be encopretic, smear, hide their excrement, relieve themselves in unusual places, or keep used sanitary wear. They may withhold their faeces for days or weeks. They may offer their bodies for sexual gratification, feeling rejected when the offer is not accepted. These actions, Carter argues, can be expressions of anger, confusion or uncertainty. These are not just difficulties for the child. Carter observes that they create feelings of confusion, helplessness, repulsion and anger in carers, which if not contained in a helpful way, (that is, seeing their link to poor early primary experience) can exacerbate the anxiety the children have and further fuel the dynamic which drives it (p. 141).

In ‘Relationships and the Therapeutic Setting’ Alan Worthington examines the statutory social care frameworks which govern the work of all children’s homes and finds the implication that ‘sound’ relationships develop between children and adults naturally, so long as they are based on ‘honesty and mutual respect’ and are contained within ‘safe, consistent and understandable boundaries’. He thinks this stated view of relationships in residential settings is a ‘simple’ one. He believes it is a view which implies an ambivalence and defensiveness arising from concerns about the consequences of inappropriate adult-child relationships, not just for children but also for social workers and social work managers. For Worthington, this represents a shift away from welfare, psychology and understanding of relationships, towards a preoccupation with rules, guidelines, procedures and the law (p.150).

While he believes that young people in residential care have opportunities to have relationships with adults that are both formal and informal, and arise out of different social and professional interactions, Worthington suggests that the increasingly defensive nature of regulations and guidelines are getting in the way of the development of relationships which have the potential to be therapeutic (p. 151).

Among these regulations and guidelines are stipulations about the recruitment and induction of staff. Worthington speaks of the importance of the selection and recruitment of staff without referring to their induction and training (p. 152). I think to separate the selection and recruitment of staff from their training is an unhelpful artifice. If a child care organisation intends to train staff, which the regulations say it must, then staff should be recruited who have the inclination and ability to benefit from the training which is to be provided.

Worthington also focuses on the significance of the keyworker’s role in the residential child care setting. The keyworker’s principal task he suggests is to become the person who carries out the institution’s overall responsibility to the child, and to be the person who holds everything about the child and his needs and concerns in mind, just as a good parent would (p. 155).

He highlights the significance of the dynamic of the manager-child-keyworker triad within the larger group, since issues to do with transference are more often powerfully evoked by senior members of staff. He adds that a crucial part of the network of relationships within the institution is not only the child-adult relationship, or the relationships the children have with each other, but also the relationships the adults have with each other and the impact this has on the children (pp.156-157).

Another significant factor in the child-adult relationship for Worthington, is how these provide a container of the children’s relationships with each other. If they are able to turn to adults to have their emotional needs met, they are less likely to turn to each other inappropriately or destructively (p. 156).

In a chapter which is otherwise helpful to managers and workers alike in all residential child care settings, for me Worthington blots his copy book when he suggests that perhaps 80% of cases of looked after children using the social care model are being looked after adequately. He provides no evidence to back this up, but if he includes, as I suspect he must, those children who are resident in children’s homes other than therapeutic communities, then he knows his claim is not accurate. (While accepting that every child is unique, there is not one case history of a child in this entire book, which in terms of the catalogue of emotional problems experienced is not replicated in the problems facing children who are placed in children’s homes).

Worthington uses the succeeding chapter, ‘Structured Work : The Space to Think’ to propose that all the formal structured spaces which are created in a therapeutic community in order that particular dialogues, activities, and group meetings take place, are for therapeutic purposes. Included in these spaces are ‘dialogue with families’ and he honestly mentions the difficulties these dialogues present for a therapeutic community (pp. 162-163). Worthington does not explore this matter at any length, but I will take it up later. It is a present and crucial dilemma for residential child care as well as it is for social work.

Andy Lole’s contribution, ‘Developing the Quality of Teaching and Learning in a Therapeutic School’, recounts how he re-developed the curriculum at the Mulberry Bush School when he arrived there in 1984. The first stage of his development plan was to create an educational structure for the school which defined what the school was trying to achieve. They decided the foundation of this should be based on the national curriculum so that children at the school would have access to the same learning opportunities as all other children in the country (p. 177). While respecting Lole’s claim to have achieved this, such is not the educational experience of children in children’s homes. An inordinate amount of children in residential care do not attend school full-time; many have been excluded from mainstream education on more than one occasion and by more than one school. A significant number are provided with only part-time education and a significant number do not attend school at all. In general, insufficient resources are provided for these children to allow for the breadth of access to the national curriculum Lole claimed for his children. In my view the education system is institutionally prejudiced against these children.

Lole goes on to express his resistance to temporary or supply teachers. He explains how uneasy this makes the children. In most children’s homes there is a preponderance of temporary or ‘agency’ residential child care staff who know little of the children for whom they are caring . These are staff who, having no contractual obligation to the local authority or the private organisation managing the children’s home, may come and go as they please. Children are continually ‘looked after’ by staff who are strangers to them and who own no professional or emotional obligation to them. What price here for the healthy ‘sound’ relationships between adult and child where ‘honesty and mutual respect’ is founded upon ‘safe, consistent and understandable boundaries’ ? These are the relationships which Worthington, with some irony, I suspect, earlier reminded us were written into the minimum statutory standards.

Workers in children’s homes have long known that legislation does not guarantee that children will be properly cared for. The regulatory bodies are here engaged in hypocrisy. They know that far from ‘good enough’ practice goes on.

Jane Pooley, in ‘Keeping Families in Mind’, proposes that therapeutic residential settings concentrate their activities into establishing a safe and nurturing environment in which the child can slowly begin to feel tolerated and cared for. They are places where he can learn, perhaps for the first time, how to respond to adults who act sensitively within appropriate boundaries. Yet she cautions that staff in the therapeutic group must not be lulled into forgetting that, whatever they may wish, think or do, the child will place great importance upon his or her family (p.187). This is equally true for children in other children’s homes. The 1989 Children Act champions the right of families to stay together. If a child does have to leave his family then the Act insists that, where it is in the best interests of the child, work should be done towards bringing the family together and enabling it to become a functional group . This was a noble aim, but in practice it has often been found to be unsustainable. Although the contributors to this book provide examples of work which has to some extent enabled families to re-unite, the evidence available to me is that only a minority of young people in residential care have access to these sophisticated family support services. It is a mantra of this book that therapeutic communities can work effectively with families of the children they look after. Research suggests otherwise (see for example Little, 1994). Though Pooley claims that since the 1990s the United Kingdom government departments have taken seriously the need ‘to support the fabric of family life in our society’, I fear this is not the case for most of the families of children who are looked after in children’s homes. The case history which Pooley provides is an example of effective work done with a family after a child has left a residential school . Yet I fear it is one of the few exceptions which prove the rule. Most therapeutic communities are too geographically remote or too remote in terms of their mode of practice to work effectively with families while the child is placed with them. However, even those children’s homes which are located close to the family homes of the children they look after have not been able to return children to the family home in significant numbers.

A case which came to my attention in the course of my work as a consultant to a children’s home in the private sector was that of a sister and brother, Emma and Edward who at the ages of 14 and 13 years respectively were placed in a children’s home which was only a few minutes journey from their family home. There was an intention that staff would work with the children to help them overcome their presenting problems, while the social worker offered support to Edward’s and Emma’s parents to help them work through the causes of their violent behaviour towards their children. This violence seemed to be a consequence of their alcohol abuse. The social worker abandoned this work after her first visit to the parents because she found them too threatening to work with. At the same time she was required to take on the case load of a colleague who had become ill, and so she would have had no time to do the work with the family. The local authority had insufficient staff to provide someone to support her in the struggle to engage with the family. The staff at the children’s home were able to build up a relationship with the parents which meant that the children could occasionally return home, but they did not have staff resources to work with the family as a group. They were not able to effect any real improvement in the family dynamic, and so the plan to re-unify the family was effectively abandoned. This lack of resources to do effective work with families while children are placed in children’s homes is more prevalent than is admitted, and though some families may have access to some of the special resources which Pooley and some of her fellow contributors describe, many do not.

Richard Rollinson introduces the section on management and development by reflecting on his own experience of being a leader in a therapeutic environment when he was theDirector of the Mulberry Bush School. He stresses the responsibility which is placed upon the leader of a therapeutic community to contain the anxiety of both staff and young people. Given the nature of the task he suggests that while it is pointless to believe that anxiety can be eradicated, it is important to recognise anxiety where and when it occurs and to work on it. It is, he asserts, the responsibility of the leader to ensure that ‘anxiety management is happening regularly and reliably at all levels of the organisation’ (p. 214). If this is to be effective then the leader must be free to exercise sufficient authority and power. Such authority and power must be exercised in tandem. If they are not they can lead, at one extreme to omnipotence in a leader or, on the other, to impotence. It seems that the defensive nature of so many of the regulations governing children’s homes, lead to managers of children’s homes nominally having authority but being so constrained by the regulations that they are impotent to act.

What Rollinson does not discuss is the effect of external assaults on the authority and power of the leader in the residential child care setting and consequently on the therapeutic work of a children’s home. This is as much a problem for managers of children’s homes in the private sector as it is a problem for the managers of local authority run children’s homes. All too often managers of children’s homes are governed by the external agenda of social workers or social work managers who, it can appear, arbitrarily end children’s placements without any consultation with staff at the children’s home. The manager of the children’s home in which the aforementioned thirteen years old Emma was placed with her brother Edward because of the violence associated with the alcoholism of her parents, recounted to me how before Emma’s admission to the children’s home, in order to escape the violence at home, Emma would frequently run away from the family home and stay out overnight, thus putting herself at further risk. Edward who remained at home continued to fall victim to his parents’ physical abuse during their drinking bouts. Three months into her placement at the children’s home and after three months of trying and intensive work with Emma, the residential child care staff had helped her to bring an end to her absconding. Emma was now measurably in less danger, but she was not attending school. She had not attended school since she was 10 years old and, given the length of time she had been away from it, returning to school presented a threat to Emma. At this time, when the staff at the children’s home felt they were beginning to help Emma confront these anxieties about school, a new social worker was appointed to work with the family. This social worker who was inexperienced and under pressure from her manager to keep down costs, was concerned that Emma was not attending school. She told Emma that she was not making use of her expensive placement and that if she did not begin to attend school by a certain date in the near future set by the social worker, she would end Emma’s placement at the children’s home. This ultimatum served only to make Emma more anxious about returning to school. When she did not attend school by the given date, the social worker arranged for Emma to be placed at a boarding school which was over a hundred miles away from her parents’ home and the children’s home where Edward her brother continued to reside. The manager of the children’s home protested to Edward’s social worker and her manager about the decision which had been taken, but although after some months the local authority social services department acknowledged that the case might have been managed better, the damage to Emma had been done.

I will return to Emma and Edward again, but their story so far exemplifies how the manager and her staff were dependent on the quality of the professional insight of the person who held the power of decision in a child care case. Here it was the social worker whose decision rendered the manager of the children’s home and her staff powerless to act on behalf of the child. The manager, who with her staff had achieved so much in containing Emma’s anxieties by holding her emotionally to the extent that she no longer absconded, was no longer able to contain the staff’s anxieties because it was evident that she had no authority or power. Neither could the manager contain the children’s anxieties because it was clear to them that she was powerless to alter their fate. Here we are not considering the dilemma Pooley describes, when she discusses family work as needing ‘to hold both the hope of being able to help the young people and their families or carers solve the difficulties that have brought them into the service, whilst at the same time holding the often unacknowledged and unconscious wish for the therapeutic community to fail in bringing about change’ (p. 189). In the case of Emma it was not only the unconscious wish of the family which seemed to impel the children’s home’s support of her towards failure, this new dynamic – the omnipotence of an external agency – rendered positive residential child care impossible.

Entwined in the story of Emma and Edward is a sad and tawdry sub-plot which requires me to relate a little of the recent history of residential child care. As the numbers of children placed in residential child care during the 1980s and 1990s reduced, the voluntary sector, as represented by the large charitable child care organisations such as Barnardos and the Children’s Society, has almost completely pulled out of residential child care. During this period, local authority provision ( that is provision directly funded by public taxation) has also significantly decreased. The voluntary sector retreated from residential child care, because it felt its child care effort could be put into other preventive ventures, and because following a number of well publicised investigations into child abuse in residential child care, it regarded it as too risky a business to be in ( see for example Children’s Society, 2005). Since the 1970s local authorities had been increasingly unable to control the cost of running children’s homes themselves, and so they began to reduce their residential child care provision and moved towards placing children in foster families. Living in a substitute family was becoming regarded as a more stable emotional environment for a child. At that time placing children in foster families was significantly less expensive than placing them in residential care.

The retreat of the public and voluntary sectors from the troubled world of residential child care created a service vacuum. There remained a significant group of young people whose needs could not be met by a substitute family. What remained of residential child care in the public and voluntary sector was insufficient to meet the needs of these children. To bridge this gap successive government encouraged the private sector to enter the field. Private organisations set up and ran children’s homes for profit. Local authorities purchased their services. The continuing ethical and political debate about whether health services should be provided solely by the public sector or whether the private sector, with its interest in profit making, should be involved in providing health services was repeated in the field of residential child care. Local authority social services departments may not have the resources to provide residential care for all those young people who need it, yet they remain critical of the private sector which stepped into the breach they created. For them the private sector appears to be about profiteering. This is a prejudice which I believe is institutionalised within social work. The line this argument takes is that it is wrong to make a profit out of children.

Personally I have some sympathy for this argument. Still, I am not, as a consultant to private child care organisations, and as I suspect my colleagues employed by local authorities are not, reluctant to pick up my pay cheque at the end of the month. It seems to me that national and local government has long held that the electorate are unwilling to pay the costs that would be incurred if the public sector monopolised the provision of residential child care. Whether it is right or wrong, the private sector is providing residential care for children. These services cannot be closed down overnight because there are no resources available to replace them. For the foreseeable future private sector is here to stay. Everyone indirectly or directly involved with residential child care should accept this at least in the medium term and they should be concerned to take up their responsibility to ensure that the private sector provides a quality service.

In my work I have found, and I hope I have helped to develop, good residential child care services in the private sector. I am aware profits are made but it is not my experience that the children’s homes shown in the television programme I watched are typical. Of course poorly managed local authority social services departments will be ripped off by rogue providers from the private sector and that is something they must address, and they have at their disposal services such as the Department of Health’s Commission for Social Care Inspection to help them address it. It is absolutely right that taxpayers get value for money. But what makes this tale tawdry is that local authorities are not altogether innocent of sharp practice.

I have been made aware of a number of cases in which a care manager of a private children’s home has been approached by local authority social workers or their managers in order to refer a child. They express their satisfaction that the children’s home meets the particular child’s needs. At the same time the social workers or their managers mention the existence of another unnamed residential resource which is less expensive. It is made clear to the care manager of the children’s home that the child will not be placed with her unless her home can provide a service at the same or a lower price than one which it is claimed the unnamed resource is quoting. The manager of the children’s home is told that her children’s home is much more suitable for the child but that it is too expensive. This is not a tawdry process because the cost of the service is being squeezed down, although it does place private organisations which invest heavily in order to provide a good service for the children they care for in an invidious position. As I understand it, private enterprise cannot survive indefinitely if it is making a financial loss. It is the underhand reverse auction of a child which is tawdry. If as a community we are unable or unwilling to meet the cost of providing as well as we might wish for these children, then we, or at least our political representatives should at least be open and honest about it. I am not condemning the social work profession. We are all involved in this pretence. The social services departments we as taxpayers fund are invariably understaffed, and individual social workers are too often given workloads of unmanageable proportions. The problem I have exposed may not yet be prevalent in social work, but it is a significant one and particularly so for children who are placed in residential care. The social workers and social work managers play the game I have described not only for their political and financial masters but also for us. They do not seem to feel empowered to blow the whistle on this pretence. Whatever it is I have described here it does not embrace the spirit of current legislation for children. It does not resound with the paramouncy of a child’s welfare.

Michael Maher is less tendentious than I am about the ethical dilemmas which arise from the economics of residential child care. In ‘Therapeutic Childcare and the Local Authority’, Maher suggests that the problem is engendered because ‘local authority social services are driven by twin imperatives: the need to manage increasing levels of need and expectation within generally static or diminishing budgets and a need to avoid unacceptable levels of risk’ (p. 279). The question is, ‘Whose risk?’

Maher is the only contributor to this book who fully acknowledges that residential child care exists outside therapeutic communities and spends some words on the plight of children’s homes both in the statutory and private sectors. It is important to draw this out because while there is great stress placed by all the authors on the efficacy of therapeutic work with children particularly in residential therapeutic communities little or no mention is made of other children’s homes. Linnet McMahon, for instance, in ‘Applying the Therapeutic Model in Other Settings’, suggests that the therapeutic model may have relevance to ‘troubled young people in adolescent mental health units, secure units and young offender institutions’ (p. 262) and as a model for carers holding the fostered child, but she does not include children’s homes. This may be an oversight, or perhaps there is an implication that it would be understood by the reader that children’s homes are included, or, thinking psychodynamically, the unconscious is at work.

When considering ‘the therapeutic approach and the holding environment’ (p. 260) McMahon opens the readers awareness to the perils of this work for both children and staff if the emotional boundaries in a group living setting are not managed. Where staff cannot contain themselves or are not contained by their colleagues, dangers abound. Evidence of this comes to my mind in an event which involved Edward, Emma’s sister. Brett, a residential child care worker and Edward’s keyworker, thought he had built up what seemed a very healthy relationship with Edward. Edward always rushed to see Brett when he came on duty and was keen to join in any activity Brett suggested they should do. They particularly enjoyed making music together on the guitar and a keyboard. Managers were concerned that the relationship between Edward and Brett was more of a peer relationship than that of an adult and child one, but since Edward seemed so content with the situation, the relationship was allowed to continue along the lines it had developed. When his sister Emma’s placement was abruptly ended, and she was placed at a distant boarding school, Edward became unhappy and displayed this by being demanding and verbally aggressive to his peers and the staff. A few days after his sister’s departure, Edward demanded his pocket money a day early, and Brett refused to give it to him, because it was breaking the home’s rules. Frustrated and angry at this refusal Edward approached the senior member of staff on duty and demanded his pocket money. Harassed and tired following interaction with other children, the senior member of staff agreed to give Brett his pocket money early, rationalising this by saying she knew he was unhappy because he was missing his sister. As she gave Edward the money Brett walked up to them and said that Edward should not get it. The senior member of staff told Brett that on this occasion she was making an exception. Edward said to Brett, in what Brett thought was a triumphant way, ‘See, you were wrong, I should have got the money, and I’m getting it’. Brett, feeling defeated by Edward and unsupported by his senior colleague, remarked as he started to walk away, ‘Yeah, Edward, thanks a lot.’. Edward rushed towards Brett and shouted, ‘What do you mean by that you wanker ? I know where your girl friend works and I’ll make sure she gets raped’. In an instant Brett rushed towards Edward and punched him on the side of the head. Brett told the senior worker that he was going home and he didn’t care if he lost his job.

Subsequently it was discovered that some weeks before the incident Edward and Brett had been out on a shopping expedition, and Brett had pointed out to Edward the place where his girl friend worked which was a hostel for young men leaving care. Later, Brett also disclosed that at the time he assaulted Edward , a young man at the hostel where his girl friend worked had tried to assault her sexually. Of course, Brett lost his job, and given the regulations which govern child care, it is almost certain that he will not be able to continue his child care career. Following the incident Edward was confused and devastated. His sister had suddenly been separated from him, and now he had lost a relationship which had seemed to carry hope for him but which now reinforced for him that adults he believed should care for him, seemed inevitably to abuse him.

I sight this case to under-line McMahon’s point that therapeutic work with young people puts extraordinary demands on the ‘self of the worker’ whose personal engagement with a young person can arouse powerful feelings which need to be thought about rather than ‘defended against’ by avoiding, projecting and splitting. She also points out that it is not only the children who need containing. Carers need containment, too, ‘since effective work requires the provision of a mental space in which it is possible to think about the meaning of a child’s behaviour, and to respond accordingly, and in a co-ordinated way with other people in the child’s life’ (p. 260). This space was not available in the event I have just described. This incident did not happen in a therapeutic community but in a local children’s home with well meaning and NVQ trained staff.

Residential child care as practiced in children’s homes needs all the help it can get. For decades children’s homes have been condemned, sometimes with justification, as being evil nests in which the abuse of children is widespread. Little is said of the many people who work in children’s homes who are on the face of things trying to do a good job for the youngsters they look after. Yet good intentions are no substitute for the information and insight provided by a relevant training. Those who have the influence to positively change this, government ministers, directors of social services, the proprietors of private child care organisations and the leaders of the other caring and educational services, for reasons which may be economic and are certainly about retaining power at others expense, are not committed to encouraging residential workers to understand their task as the complex one that it is. This is why Adrian Ward, the first named editor of this volume, and all the contributors to it are to be congratulated in bringing to our notice how rich a contribution to the care of troubled young children well thought out, planned, pyschodynamically based residential child care work can make.

Here an important qualification – implicit throughout this review – has to be made. In the main the therapeutic services described by Ward et al, are available to only a small minority of the children and young people looked after in the public care. In the main the authors discuss what is provided for children who are looked after in what is by its very nature a philosophically, and often geographically, isolated therapeutic community. I gain an impression that therapeutic child care has a vested interest in claiming to be special and exclusive. Perhaps this is what makes it different, ‘better’ than the rest. I would cede this status to the authors of this book if they did not resist – in the way I resisted the television programme – the task of confronting the problem which besets the wider residential child care service. They do not address the problems within the residential child care services provided for the majority of children who are looked after in a residential group setting. The children I refer to here are those placed in children’s homes where any theoretical underpinning of the care provided is based on an untested amalgam of the notions of child care which are held by staff – and I don’t necessarily mean the management staff – who currently hold power within these homes. There are some notable exceptions but the children and staff of many children’s homes find themselves in an environment which is inconsistent and disorienting.

In not engaging with these issues the authors of this book may have to accept that a possible consequence of claiming exclusivity is that those you don’t include or don’t join, may dismiss you. Fortunately Alan Worthington, one of the editors of Therapeutic Communities for Children and Young People has anticipated this. In September 2004, he gave a talk at an international conference in Glasgow. It was entitled, ‘Therapeutic Communities, Will They Survive?’ I feel this book – which tells us with breadth, depth and clarity how psychodynamic theory and the practice based upon it, can bring hope and well being to unhappy children. – would have been more ground breaking if it had addressed Worthington’s question, particularly in relation to what the therapeutic community approach can usefully give to the rest of the residential child care service. It can appear as if those who uphold the therapeutic community cause are merely in a dalliance with a real world that is too painful to engage. The therapeutic child care movement needs to situate itself right in the centre of the world occupied by the rest of residential child care.

 

References

* ‘Dispatches : Profiting from the Child Care Business’. Channel 4 November 25, 2004.

Association of Therapeutic Communities (2005) Populations Served: Children and Adolescents. Accessed on-line at http://www.therapeuticcommunities.org/directory.htm

Bettelheim, B. (1974) A Home for the Heart. London: Thames and Hudson.

Charterhouse Group (2004) ‘Planned Therapeutic Placements’, December 2004. Accessed on-line at www.charterhousegroup.org.uk/

Children’s Society (2005) ‘1970s to 1990s — Replacing Residential Homes with Innovative Community Projects’ in A short history of The Children’s Society. Accessed on-line at http://www.the-childrens-society.org.uk/learn/SG Feature/5926/2/

Department of Health (2002) Children’s Home: National Minimal Standards: Children’s Homes Regulations. London. Department of Health.

Department of Health (2005) National Tables, Accessed on-line at http:/www.dh.gov.uk.rsgateway/DB/SBU6000552/nationaltables/finalrevised.xls#Table%20A1A1

Dockar Drysdale, B. (1993) Therapy and Consultation in Child Care. London: Free Association Books.

Klein, M. (1921) ‘The Development of a Child’ in Love, Guilt and Reparation and Other Works. 1998. London: Vintage.

Klein, M. (1952) ‘Some Theoretical Conclusions regarding the Emotional Life of an Infant’‚ in Klein, M., Heimann, P., & Money-Kyrle, eds. New Directions in Psycho-Analysis London: Hogarth, pp.198-236.

Little, M. with Siobain Kelly** (1995) A Life Without Problems: The Achievements of a Therapeutic Community. Aldershot: Arena. ** Nom de plume of a child in care.

Menzies Lyth, I. (1988) Containing Anxieties in Institutions. London: Free Association Books.

Redl, F. (1966) When We Deal with Children. New York: The Free Press.

Sharpe, C. (2001) In Care, in Therapy? MA Dissertation. University of Sheffield.

Waddell, M. (1985) ‘Living in Two Worlds : Psychodynamic Theory and Social Work Practice’, in Free Associations Vol 10. Accessed on-line at http://human-nature.com/free-associations/waddell%20-%20living_in_two_worlds.htm