Therapeutic Communities, 30, 2, summer 2009.
The Mulberry Bush School is a non-government-maintained special school with charitable status. The primary task of the school is to provide therapeutic care, treatment and education to severely emotionally deprived boys and girls aged between five and twelve who are referred by local authorities from all over the UK.
Our aim is to re-integrate children who have experienced severe trauma due to early environmental failure back into mainstream family, school, and community life.
Consequently, this failure requires the school environment, both physical and human, to be felt as robust and resilient. A healthy tree in a strong wind needs to be flexible enough to bend but not break, to spring back from the impact of the storm. The roots of the tree as the anchor have also to be resilient. Winnicott’s concept of ‘the use of an object’ (1971), the therapist who is tested to destruction by the child, but seen to survive, remains a useful psychoanalytic concept. The following case study explores the aetiology of the environmental factors that led to Danny coming to the Mulberry Bush School. All names have been anonymised.
During Danny’s infancy his mother found it very difficult to provide the consistent care and nurture that he needed because of her own mental health issues. Danny internalised this experience of emotional absence, and we can imagine that as he grew to be a toddler he began to ‘expect’ neglect, and conversely became increasingly self-reliant in order to meet his own needs. By age six, without any active parental guidance, he was absenting school and took to wandering the streets with his sister Pat.
Understanding narrative: our history as a ‘container’
An evolving relationship between underpinning theory and practice
Dockar-Drysdale has done her most important work in seeking to explain the nature and needs of the ‘frozen’ or psychopathic child. The emotionally deprived child is seen as ‘pre-neurotic’ since the child has to exist as an individual before neurotic defences can form. The extent to which there has been traumatic inter-ruption of the ‘primary experience’ decides the form of the disturbance. A child separated at this primitive stage is therefore in a perpetual state of defence against the hostile ‘outer world’ into which he has been jettisoned inadequately prepared.
Using the lived experience as a medium for therapy: planned environment therapy
Dockar-Drysdale developed her work in an era when group psychotherapy was still in its formative stages: the Northfield experiment and the associated 1946 bulletin of the Menninger Clinic papers that launched the Therapeutic Community (TC) movement were still recent innovations. She had met the psychiatrist Marjorie Franklin, and David Wills who via the ‘Q’ camp experi-ments of 1936–1940 had already defined ‘planned environment therapy’. By 1945 Franklin had written and published her manuscript ‘The use and misuse of planned environment therapy’.
The roots of planned environment therapy reach back to 1928, when before her involvement in the planning of the ‘Q’ camps Marjorie Franklin set up a ‘psychological and psychotherapeutic discussion group’ at her consulting rooms in Harley Street. Meetings of this group included the psychoanalysts Dr Kate Friedlander, Dr Melitta Schmideberg (Melanie Klein’s daughter) and Dr Adrian Stephen. The ‘Q’ camps’ planning committee also included Dr Denis Carroll of the Portland Institute for the scientific study of delinquency, who later worked as an army psychiatrist at Northfield.
By 1963 Franklin had set up a planned environment therapy discussion group, which led in 1966 to the formation of the Planned Environment Therapy Trust to promote ‘the serious clinical study of the use of the environment as a means of correcting asocial and other related character deficiencies.’ Franklin claimed that ‘planned environment therapy has long reached the stage of a serious branch of psychotherapy,’ and Arthur Barron described it as ‘the only method that provides a viable method and approach to the residential care and treatment of the maladjusted’ (Bridgeland, 1971).
The concept of Planned Environmental Therapy, using the totality of the environment including the diversity of relationships, and everyday activity in service to the recovery of the child, helped develop the concept of the school as an integrated and holistic TC environment.
The strength of this model is in the ability of staff to tolerate and contain high levels of disturbance and emotional pain, and to offer reflection and understanding to the children placed in it.
For children such as Danny the concept of the community offers a multitude of meanings and layers of experience which over time can be internalised by the child. Our model of education and group living is role-modelled by mature adults. Children live in a group but more importantly as a group. They play and do their school work between different groups. This combined patterning of the community creates and builds a day-to-day experience of ‘the other’ which requires children to challenge their self-reliant and mistrustful view of the world, and start thinking about the ‘social and emotional’ through cooperation and the understanding of other individual and group needs. As a society in miniature it provides the condition where disaffected children can develop a sense of the value of the group and community using the medium of group discussion, consensus and conflict resolution. The community is containing for the children because every interaction can be observed, managed and talked about. Such a sense of purpose is built into the everyday routines and activities.
The therapeutic effect of community living is multi-dimensional. For the first time in his/her life, a child might see another child who has similar or greater difficulties than him/herself; or that another child who one year ago was ‘impossible to manage’ is now talking with concern about his key-worker or teacher. Internalising such experiences over time helps children feel they are no longer alone or marginalised in an apparently hostile world. There is an African saying that captures this dynamic: ‘It takes a whole village to raise a child.’
The risk of enmeshment in the ‘regressive tug’
Within the school environment chaotic, aggressive and sexualised ‘regressive’ behaviours of children are often the primary emotional currency. In one sense the transference which children project onto staff members is too readily available. We also need to be aware of how the unconscious infantile needs of staff members are reactivated within this work in order to reduce these being acted out in the workplace. The role of reflective spaces, supervision and consultation to support and develop the understanding of members of staff engaged with these processes remains a key component of the work.
Several years ago ‘Ronnie’ aged five was referred to the school. On his arrival staff talked about their positive feelings of working with such a little boy. Some members of staff were drawn into this way of relating, and Ronnie played into these relationships which focussed on a positive transference. When Ronnie started to act out his abusive past through aggression towards these staff members, they realised that they had become involved in a complex enmeshed relationship with him.
Within this continuous evolution our current model of integrated therapeutic provision is being carried out by members of the different departments of group living, psychotherapy, education and family support, organised as a ‘treatment team’ to meet the needs of the child. This work was previously provided by the individual ‘focal’ therapist. The aim of this approach is to meet the needs of the child from a group perspective, rather than facing the situation of ‘vertical dependency’ with individual workers risking isolation or enmesh-ment by feeling singularly responsible for meeting the ‘bottomless pit’ of needs. In this way the ‘horizontal’ structures of the teams act as ‘anchors’ to counteract the downward regressive tug with an upward ‘pulling force’, providing direct support, feedback and direction for the individual worker.
This is not an avoidance of individual work. Children still have key-workers, and planned and spontaneous individual times for work and play, and many have access to regular child psychotherapy sessions. Our approach relies on members of the organisation individually and collectively being in touch with and supporting each other to develop a capacity for ‘negative capability’ or staying with not knowing in the face of challenging behaviours.
The following observation by Deputy Head teacher of the school, Catherine Mattachine-Lee, of a circle time session in a classroom situation captures this therapeutic group-based model of working together.
There were four children and four adults in the class, all of whom were sitting on cushions in the reading area.
Jessica introduced the lesson by clearly explaining that the theme of circle time would be ‘Our Worries’. She then read to the children a poem written by mainstream school children about their own worries. The poem clearly indicated that these children thought they were the only ones to have these particular worries. I was immediately struck by the emotive subject and wondered how the children would cope.
As Jessica finished by reading a worry about losing a pet, Peter said something clearly very unkind to Gary who became quite distressed and ran out of the class. The Teaching Assistant who was sitting with Peter immediately acknowledged that, while what he had said to Gary was unkind, she thought Peter was probably quite worried about a lot of things. This response calmed Peter who had become quite agitated and he replied, ‘Yes I am.’ He then sat very close to the Teaching Assistant, holding her hand.
Gary was able to return to the classroom greeted by an apology from Peter and a lot of praise from the adults for being able to come back in.
Jessica then explained that, although the children who wrote the poem had thought they were the only ones who had worries, she knew that all the children and adults in the class probably had similar worries at one time or another. She had written on strips of paper the worries from the poem and asked each child in turn to pick one. She explained that with most worries we can do something about them and wanted the children to think about whether their worry could be resolved or not. She pointed to two areas on the carpet labelled ‘worries I can do something about’ and ‘worries I can-not do anything about’. In turn each child read out the worry and thought about where to place it.
Michelle, who had been to therapy, joined the group and was able to engage immediately with the activity, which I felt was as much due to the way in which she had been welcomed into the room and the calm and thoughtful atmosphere within it.
When it was Sanjiit’s turn, he clearly couldn’t find his voice to explain about his worry so used his teddy bear via another Teaching Assistant to speak on his behalf. Sanjiit held teddy up to the assistant’s ear and she listened quietly to what teddy had to say and then told the group. Sanjiit was clearly delighted that the Teaching Assistant had heard him and knew what was on his mind.
The children were then asked to comment on which section of the floor had more of the worries on it. They were very in touch with how most worries can be resolved in some way. Peter commented that it’s good to talk about worries ‘because it can make them go away.’
As an observer, I was struck by the pain the children were displaying as they talked in the circle, all of whom were generally very respectful of each other and how the adult group was able to hold the pain for them. It could have been a very different outcome if the staff hadn’t been so containing. As a lesson it was a risk, but a risk which Jessica and her staff took with great skill and thoughtfulness. It was an excellent piece of work and a privilege to have been allowed to see it.
Developing appropriate emotional distance regulation
It is for these reasons that we continuously work to support and clarify the task of all staff at the school. We require teams to support their members to think carefully about the relationships they are engaged in with children. Team members use their colleagues within team meetings to help them think and develop ideas about their relationship in relation to the child’s care and treatment. We require members of staff to be observant, creative, sensitive and thoughtful in their interactions with children, and to use the team and the support structures for reflection on their work.
This requires staff members to be supported to ‘inhabit’ a ‘boundary position’ in their minds from which they can interact in the inter-subjective relationship, and yet observe in order to develop a hypothesis about which aspects of the child’s functioning (or lack of functioning) needs to be supported or treated. This distance regulation does not mean the worker withdrawing from the child; rather, it means creating an appropriate thinking space. Our aim is that this work enacts the theory of emotional containment (Bion, 1962) whereby the primary carer receives the ‘transmission’ of impulsive feeling from the child and, through digestion and reflection on this impulse as a com-munication, they can offer a thoughtful response to meet desired need and facilitate emotional growth.
Ultimately, members of staff are there to meet the child’s needs, not to have their needs met via the relationship. There are regularly times when workers feel overwhelmed by the confusions and powerful projections from children. At these times the teams are facilitated to reflect on these dynamics and the enmeshment, and to use the support structures to help disentangle and provide re-direction for the worker.
The business of setting up the therapeutic system is, therefore, the business of setting up structures to reduce the effect of the staff unconscious on the staff/child relationship and to maximise the chance of detecting the effect of the child’s inner world on the system. (Stokoe, 2003)
Robust boundary management as a container
The literature on the history of the school shows the working model to be of Barbara and her colleagues engaged in close one-to-one therapeutic relationships with the children; the lived experience was literally of ‘continuous therapy’.
The unending demands on the physical and emotional energies of the staff, particularly as it was the principle of the school never to close, produced new problems in the management of the school, now brought into closer contact with the expectations of the outside world. (Bridgeland, 1971)
The concept of the school as a ‘sanctuary’ or ‘asylum’ has been a core principle of our work. Reeves (2002) defines the theme of ‘Impact and Impingement’ as an issue for the school; the child, and the therapeutic relationship, is largely protected by boundary management from the impingements and dynamics of the ‘outside world’.
The development of therapeutic management structures at the school is a story in itself. Since 1991 the structure that has been formulated is that the Heads of the four departments – Group Living, Education, Psychotherapy and the Family and Professional Networks team – are accountable to the Director who is responsible for the day-to-day management and development of the school. In 2006 the role of Chief Executive Officer was created in response to a rapidly changing external social care environment. This has allowed those in role a more focused and dedicated preoccupation with the inner and outer worlds of the school. Like the Roman god Janus, who had two faces, one looking out of the city and one looking in, the concept of boundary management implies the ability to maintain an overview of the internal dynamics and attend to the demands that come to us from the outside.
The concept is useful for any worker engaged at any level of the organisation. Eric Miller wrote that, ideally, every worker could be their own manager, implying the ability to develop an observational stance or third position to manage one’s own task responsibilities and the interfaces with others’ tasks in relation to this.
Boundary management implies the ability to be the overall ‘gatekeeper’ of the task. A healthy system, like the biological model of the plant cell, interacts with its environment absorbing carbon dioxide and passing out oxygen. This implies the function of acting as a ‘filter’ to the issues and dynamics that are ‘imported’ across the boundary into the organisation.
Boundary management also requires the ability to be able to go inside or outside but, most importantly, to be able to return to the boundary position. Getting pulled inside and getting stuck there, or getting ‘lost’ outside, are potentially detrimental to the leadership and management of the organisation.
The boundary position creates a space for reflection, allowing the manager to support those who are working on the inside to ‘hold the task in mind’ and thereby creating an appropriate distance between thought and action. This principle matches the task of organisation: ultimately to help young people develop insight into their actions, and replace what one writer described as ‘thoughtless acts with act less thoughts’.
Containment and the influence of the ‘external environment’
I have explained the importance of the ‘holding environment’ as the main ‘framework’ within which damaged children can begin to evolve emotionally out of a mutually shared experience of ‘living and learning’ alongside mature and caring adults. Residential experience is constantly inter-subjective, and a systemic understanding requires us to think about the importance of the links and connections with the external institutions that place children at the school.
Traditionally in the UK, the Local Authority networks, and the concept of ‘working in partnership’ with professionals in these agencies created another containing boundary for this work. Over the last few years there has often appeared to be a pervasive and subliminal reduction, or blatant disorganisation of the boundaries around the role and task of these networks. This has led to a weakened sense of the authority of referring groups, especially in their understanding of the needs of children and the commissioning of appropriate placements for them.
Several recent writers and academics (e.g. Hirschhorn, 1997; Abadi, 2003) have argued that our concept of the ‘bounded organization’ is in flux or dis-appearing as traditional organisations and forms of communication become more ‘networked’. These writers comment on the impact of this more fleeting experience of ‘liquid modernity’ on organisations, and how it can create a lack of clarity about connections in and beyond the workplace.
Recently, I asked two representatives from one Local Authority if they could explain some of the issues which are influencing them in meeting the needs of traumatised children.
They identified that there was an increase in projects designed to keep children within mainstream schools; the ‘inclusion’ model. This model is inclusive in concept, but in reality is not always able to be supported by mainstream school members of staff that are often under pressure to meet curriculum delivery targets, and have less time to be preoccupied with meeting and managing the behavioural problems created by this small cohort of highly needy children.
They also informed me that in their view a lack of psychodynamic training, skill in assessment and lack of understanding often means that the members of staff within these projects do not see, understand or manage behaviour as a symptom of underlying need. Unfortunately, the result of this process is that many children are excluded, creating yet another placement breakdown, and experience of failure for the child.
These issues are compounded by financial budget constraints: money generally follows the placement of very troubled ‘high profile’ adolescents and, consequently, the needs of the next generation (the current fives to twelves) are not met. We can see how this market-led planning perpetuates a short-term solution to a long-term problem.
From this brief vignette we can start to see some aspects of the fragmentation of the role of Local Authority policy and services as part of the necessary ‘holding environment’ for troubled children. We can hypothesise that for staff members working with children with insecure and disorganised attachment patterns, the ‘holding environment’ created by the external networks – those that should create a sense of preoccupation and containment – is increasingly felt as disconnected, or at worst absent. As Cooper and Lousada (2005) identify:
the system of values and relationships, upon which political authority rests, no longer works to organize this domain in the way it once did. In education, social care, health, it has been replaced by the vast and complex system of regulation, inspection, performance management, and audit, which has bred a new quasi profession of auditors, regulators, and inspectors to administer and manage it.
In the absence of these more external containing structures, the requirement for our schools, homes and clinics is to evidence to those who carry out this regulation that we can move to become more ‘self regulating’. As I have explored, this requires a ‘reflective’ stance which holds the authentic needs of children ‘in mind’ at the heart of the task.
The current move to an absence of responsive containment from the wider social structures requires us as practitioners to inhabit a ‘third position’ in our minds from which we may observe ourselves and others, and thus acquire a sense of mental ‘reflective’ space in the workplace.
I have traced the development of some of the key themes and features of the Mulberry Bush School as a TC for children who have suffered severe and traumatic environmental failure, and offered case examples of this work.
Within this development I have emphasised the importance of the emotional environment, and the relationships offered by those who work within it as opportunities for individual and group therapeutic experiences, which we term ‘learning to live and living to learn’. This lived experience aims to bring about positive internal change in the children placed with us.
I have explored how the school offers the key concept of environmental containment to meet the needs of children in an attuned and empathic way. I have argued that, for successful outcomes, this function has to be carried out at all levels of the community and, finally, I have emphasised the increasing need to pay attention to this function within the wider referring networks.
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