Thursday, August 21, 2014

Models in Therapeutic Work with Traumatized Children Part 2

In my previous blog, I discussed how models develop in childhood as internal ‘templates’. By the time a child becomes an adult, he or she will have a way of relating to others based on their ‘internal working model’. Once a child is born the parents ideally have some clear ideas about what will be good for their baby, and they also have the capacity to provide it.

We all know from observing and/or being a parent that there are different versions of how to look after children. Usually, our version is based on our own childhoods, what we have learnt in our families. Most parents want to parent like theirs did, if they have internalized a positive experience of being parented. If they have not and they haven’t been able to acknowledge the difficulties, they may also parent in a similar way and repeat the negative experiences. This is how a cycle of deprivation and abuse continues. Or if they are more in touch with the reality of their own childhood difficulties, they may wish to be different than their parents and bring up their children in a better way. However, even with all the knowledge now available, few first time parents will have received much formal education on parenting.

Add into the equation that both parents will have had different childhood experiences and will have differences and similarities in their views on parenting. Some difference may be positive because it provides their children with a wider range of qualities. However, too much difference on dealing with basic issues could be too contradictory, unpredictable and unhelpful. Sometimes the parents might not be conscious of their differences until: they have a baby; their child reaches certain ages; or particular situations arise. Each stage and event of childhood can have the powerful effect of resurfacing strong feelings in the parents, related to their own childhoods, which they may not have been aware of, or had repressed. On the positive side, how the parents manage their feelings, work together and resolve differences are vital parts of parenting. It provides children a role model on how we can positively cope with difficulties and how difference can be useful rather than negative.

The relevance of parenting, is clear when we think of therapeutic models. Whether we are working in foster care, residential care, therapy or teaching, parent-child dynamics will be involved. The task will require that the foster carer, residential carer, therapist or teacher can reflect upon and untangle what is in the child’s best interests. One child who was living in a residential children’s home complained to me,

‘You can tell how all of the carers were brought up, because they all have different rules and attitudes at mealtimes.’

There is nothing like the way we eat together to highlight differences! In the absence of a clear and agreed model the carers were doing their own thing based on their personal points of view. There could be 8-10 adults in a team, so the potential for confusion is huge. It can be hard for two parents to provide the necessary consistency for a child, so providing it among a large team is challenging.

When there is a team working with a child it is especially helpful to have a model. Traumatized children need predictability and consistency, to help them feel safe and to stabilize their emotions. Only once this achieved can they begin to make use of the experiences they need to recover and develop. Without a clear model, chaos is likely to rein. For many years various reports, investigation’s etc. into ‘looking after children in care’, have found that a clear ethos or philosophy, along with strong leadership are the most consistent factors in positively run organisations that have good outcomes for children and young people. What used to be termed a philosophy of care, is now more frequently referred to as a model of care. Whether we are talking about care, therapy or teaching, having an appropriate model is essential.

A model needs to be based on the best information available for the specific task. For example, if we are teaching an autistic child, the research and theoretical base will be different to that for therapy with a traumatized child. There may be some overlaps but there will also be some differences. I had a steep learning curve, when I began work with traumatized children and another one when I moved and spent some time working with children who were diagnosed with Asperger’s Syndrome.  The model that worked with one didn’t work with the other. It can be said that in working with any child, we need to be adaptive to each child’s personality. For instance, it is now well-known that everyone has different learning styles and therefore different learning needs. But the differences between children with different types of complex needs are especially challenging to adapt to. Bessel van der Kolk et al. (2007) has said that in work with complex trauma a variety of approaches are necessary and,

“Helping people who develop posttraumatic stress disorder (PTSD) in the after­math of a traumatic experience is a complex process that cannot simply be described like a cookbook recipe.”

A model can provide guiding principles, standards, specific techniques, do’s and don’ts. But most importantly it should equip the people doing the work with the ability to think within a framework and work things out together.  A model provides parameters within which things can be tried and monitored. What works can carry on and what doesn’t may need re-thinking or persevering with. Having a benchmark provides a point from which new ideas can be critiqued. If there isn't a benchmark how do we notice how far something is drifting - a bit like walking in the fog, without even a vague marker to keep a sense of direction.

Having a good model on paper is not a guarantee of good outcomes. There are other important factors that will determine success. For example, is the model embedded in the culture, is it understood and do people feel a sense of ownership. It is particularly important that a model is culturally sensitive and takes into account cultural values, language and belief systems.

In work with traumatized children, as I mentioned in the previous blog, every aspect of the environment and how the different parts work together is vital. Different terms like, integration, congruence and joined-up have been used to explain the importance of this. A trauma informed environment is necessary and this includes everyone who is in any way involved – carers, therapists, teachers, managers, senior executives, administrators, etc. Creating this requires a cultural change because how people think about the children, the task and how they relate to each other is all relevant to the model.

Effective leadership and implementation of a model is a challenging task.  To fully establish a strong culture with a clear model can take at least 2-3 years, if not longer. By this I don’t just mean that a model is created on paper, but that it becomes genuinely reflected in the way that individuals and the organisation as a whole works. When a model is fully established, it can be recognized by the positive qualities that run through the organisation, with everyone speaking the same language. It will be reflected in the consistent quality of relationships between adults and children and at all levels of the organization. Ultimately the aim of any model is to achieve the best possible outcomes for children, so continually evaluating, learning and adapting must be part of the culture. As I have said, a model is never finished, it is always evolving.

Reference

Turner, S.W., McFarlane, A.C. and van der Kolk, B.A. (2007) The Therapeutic Environment and New Explorations in the Treatment of Posttraumatic Stress, in van der Kolk, B. A., McFarlane, A.C. and Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body and Society, New York: Guilford Press

From a great book!

Tuesday, August 5, 2014

Models in Therapeutic Work with Traumatized Children

The term model has arisen significantly during the last decade or so, to imply a well thought through and coherent way of providing a service. Other terms that may mean something similar are framework, ethos, philosophy and approach. I will describe how I see some of the important principles of a Model.

One of the first uses of the word model in our field of work may have been by John Bowlby (1969) who used the term ‘Internal Working Model’. This related to the model internalized by an infant as to how the world around him works and his place in it. The model is based on the infant’s perception of his experience. For example, I am lovable/unlovable, carers are protective/harmful and the world is safe/dangerous. It can be seen from this that the model includes the infant’s view of himself, those closest to him and the wider environment or world. The model is an internal template that the infant may not be conscious of and though it is resistant to change, it can be modified by new experiences.

As with parenting the outcomes of a service for traumatized children are going to be determined by: the quality of relationship between the child and those closest to him (parent/carer/therapist); the immediate context and quality of relationship (extended family/organization – culture, leaders, managers and supervisors); the local community; and the wider socio-political-economic environment.

While trauma may mainly be perceived as an issue between the ‘victim’ and ‘perpetrator’ it is not helpful to ignore the context or ecological aspect. Trauma happens within an environment, such as a home, a family, a neighborhood, a community and a society.  A model for recovery needs to consider not only the different levels of the context but also the relationship between them. For instance, it probably would not be helpful to create a model, however rational it might seem in clinical approach, if it conflicts with cultural values and norms. Supporters of the ‘ecological model’ rightfully argue that outcomes can be improved by intervening at any level of the context.  For example, ‘the best way to improve outcomes for young children is to improve the support provided to primary caregivers’, or ‘a reduction in poverty might reduce instances of trauma’.

If we are going to influence and change a child’s 'model' it makes sense that the approach, must also involve, working directly with the child’s internal and external worlds. This will include all of those who work with and look after him as well as the context within which everything happens. Most importantly these different elements must be integrated.  As James Anglin (2002), the Canadian researcher on residential care has said, they must be ‘Congruent in the Best Interests of the Child’.

While most people might not think consciously in terms of models, in essence it is as Bowlby described, the way we make sense of the world around us and our part in it. For example - what do I want to achieve; what are my ideas of the methods I might use to achieve it; what evidence do I have about the effectiveness of the methods; and what are the likely outcomes; including unintended outcomes or side-effects?

When we are a team providing a service, it is especially important that we have a shared model that we work to. Without this the service is likely to be fragmented, inconsistent and potentially conflict ridden. Clearly, in work with traumatized children this is not helpful. Rather than provide children with the high levels of consistency and predictability that is necessary for their recovery, the service is more likely to resemble the environments in which they were traumatized.

When I began my career in 1985 at an English therapeutic community (Cotswold Community), the organization had a very well developed model. It wasn't referred to as a model, but a therapeutic approach. The most striking feature for me was that the organizational aspects were fully incorporated into the model.  Leadership, role clarity, authority, management, structure and boundary management were seen to be equally important to the ‘treatment task’ as the direct clinical work with the children. Not only were both aspects important in their own right, the relationship between the two was understood to be critical. This can be thought of as the relationship between therapy and management. It can also be reflected in what people sometimes refer to as the relationship between ‘business and care’.

A comparison can be made with the task of parenting.  Parents with an infant strike a balance between attending to the management of the environment and focusing on the infant’s emotional/physical state. Keenan (2006, p.33) referred to Winnicott’s conceptualization of these two functions that are both necessary to ‘hold’ the child,

“The object-mother is the mother as the object of her infants desires, the one who can satisfy the baby’s needs … The environment mother is the mother in the role of ‘the person who wards off the unpredictable and who actively provides care in handling and in general management’ (Jacobs, 1995, p.49).”

Sometimes the parent may become so caught up with the infant on an emotional level that other issues are neglected, like shopping, housework, paying bills, etc. At other times the parent may be so busy with these things that the infant’s emotional cues aren't noticed. Holding the two together is a challenge that ebbs and flows.  Unless things become extreme in one way or another, the overall experience for the infant will be ‘good enough’.

From this example, it can be seen how all these aspects of the infant’s environment are connected to his overall sense of well-being. It would be no use to have emotional needs met within the context of an environment that is not being well managed. The consequences of the lack of management may lead to a deterioration that would cause stress for the parents and potential hazards in the environment, which would impact negatively on the infant. The same applies in organizations.  It could be argued that effective management provides the container in which therapy can take place………..It is crucial in the residential treatment of traumatized children that the whole organization and every activity within it are aligned to this work………Confirming the importance of this, Canham (1998, p.69) argued, “...the whole way the organization functions is the basis for the possibility of an introjective identification.” The children will internalize not only the relationships they are most directly involved with but also the way the organization as a whole functions. (The above section has been adapted from Barton et al., 2011)

The balance between the different needs described above and how the potential conflict is managed is a key part of the therapeutic task. Individual needs always have to be responded to within a context. For example, how are individual needs met within the context of group needs? We do not help children and young people by ignoring the reality of the context, which includes the resources available. We have to find creative ways of meeting needs.  For example, a parent with 5 children is going to manage things differently compared to a parent with 1 child. The outcomes for each child are determined by how the situation is managed – by the parents, the extended family and the child’s own resourcefulness. In some cultures the local community has a big role in looking after all the children. Isaac Prilleltensky (2006) argues that wellness occurs in the inter-relationship between the personal, the relational and the collective.

When I began my career we had a team of 5 care workers looking after a group of 10 children.  Nowadays, with the same type of child it is more likely to be a team of 10 looking after a group of 3. The challenging question in the face of such change is whether the core principles of a model can be sustained?

Models must be alive and adaptive – they must be open systems and have feedback loops, so they can receive the information they need from all parts of the system. In other words a model can never become a fixed entity, as one part of the system changes other parts must adapt. It must continuously evolve. For example, a change in the external environment, politically, economically, or professionally will require an adaptation. As with evolution those that survive are the most adaptive.

My next blog will focus on the specific benefits of having a model.

References

Anglin, J. (2002) Pain, Normality, and the Struggle for Congruence: Reinterpreting Residential Care for Children and Youth, New York: The Haworth Press Inc.

Barton, S., Gonzalez, R. and Tomlinson, P. (2011) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for PracticeLondon and Philadelphia: Jessica Kingsley Publishers 
Bowlby, J. (1969). Attachment. Attachment and Loss: Vol. 1. Loss. New York: Basic Books

Jacobs (1995) D. W. Winnicott London, Thousand Oaks, New Delhi: Sage Publications

Keenan, K.A. (2006) ‘Food Glorious Food: An Exploration of the Issues of Anxiety and its Containment for Children and Adults Surrounding Food and Mealtimes in a Residential Therapeutic Setting.’ MA Dissertation, Planned Environment Therapy Trust.   Available at,
http://archive.pettrust.org.uk/library/keenan2006.pdf, accessed 4 April 2011

Prilleltensky, I. (2006) ‘Psychopolitical validity: Working with power to promote justice and wellbeing.’ Paper presented at the First International Conference of Community Psychology, San Juan, Puerto Rico, 10 June 2006.

Comments

Joanne Prendergast
 - Social Care Worker at St Bernard Group Homes, Ireland
Very informative critique on the aspects of well -intended child care models. The flexibility around areas that create the holding environment are crucial to this very delicate but valuable task.

Andrew Collie - Organisational Consultant, England

Thanks for this Patrick. Child care without a model is child care without concern for the child.Models must be alive and adaptive – they must be open systems and have feedback loops, so they can receive the information they need from all parts of the system.  In other words a model can never become a fixed entity, as one part of the system changes other parts must adapt.  It must continuously evolve. For example, a change in the external environment, politically, economically, or professionally will require an adaptation.  As with evolution those that survive are the most adaptive.