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Denise Ledger
“A Family Centre approach to Early Therapeutic Intervention for Young Children and their Families
”
September 2002
Submitted in partial fulfilment for an
MA in Therapeutic Child Care
Department of Professional Education in Community Studies
This dissertation is a study of early therapeutic intervention with young children and their families within a family centre setting. Existing literature relating to family centres, family support services and therapeutic family work is explored. The context in which therapeutic work takes place within the family centre, and the environment necessary for effective work to be undertaken is looked at. The work also proposes that effective support systems need to be in place to support staff undertaking the work. A case study is used to look in more detail at the referral process and the subsequent work that takes place with parents, with parents and children together, and individually with children. The study aims to demonstrate that therapeutic work with young children and their families is complex, with each part of the work being an important part of the jigsaw of effecting change for children within their families. The study proposes that early intervention, with therapeutic help for both children and their parents, has the potential to make a real difference to children’s lives, contributing to sustained positive outcomes for children.
Chapter 3 Literature review 10
Chapter 4 The context of therapeutic work 21
Chapter 5 Work with the family: the referral stage 28
Chapter 6 Therapeutic work with the parent 34
Chapter 7 Relationship work with parent and child 41
Chapter 8 Therapeutic work with the children 48
I would like to thank everyone who has given me the support, advice and encouragement that I have needed to complete this dissertation. I am particularly grateful to the following people, without whom this would not have been possible:
The staff, and fellow students of the MA in Therapeutic Child Care at the University of Reading, especially my dissertation supervisor Linnet McMahon. Their support and contribution to my learning has been invaluable.
All the staff at Buddle Lane Family Centre for their support, ideas and commitment to the improvement of practice, and to the families who provide the learning opportunities. Particular thanks go to Pat Cusa and Lindsay Stephenson for managing the past two years at the Centre so well.
Lynn Barnett for beginning the process of change at the family centre, and for lending me her work.
Finally, but by no means least of all, my family. Roy for his unstinting belief in me, Iain, Chris and their partners for their interest and practical support, and Lily and Elsa for providing me with opportunities to stop and play.
Recent research studies, commissioned by the Government following child abuse enquiries during the 1980’s, suggest and indeed call for, a rebalancing of child protection work, stating that for vulnerable children, ‘There would be efforts to work alongside families rather than disempower them, to raise self- esteem rather than reproach families, to promote family relationships where children have their needs met, rather than leave untreated families with an unsatisfactory parenting style.’ (DoH 1995:55)
There is further guidance to inform the planning and delivery of services that can best protect children. The following points are emphasised:
The importance of sensitive and informed professional/client relationships where there is honesty and open communication.
The need to focus on incidents in context, with notions of welfare, prevention and treatment.
Protection is best achieved by enhancing the child’s quality of life, by building on the existing strengths of the child’s living situation.
My interest is in this area; in how we work alongside families, empowering both the parents and the children to promote and safeguard the longer term welfare of the children. I have worked for the local authority for over twenty years, initially as a secondary school teacher and subsequently as a residential social worker. During this time I encountered many young people who were finding adolescence particularly difficult, culminating in them being cared for by the local authority. Many of these had experienced traumatic and distressing events during their early years. For many of them this had continued throughout their childhood, with each subsequent traumatic event adding to their existing history of distress, often resulting in them being at the receiving end of a repetitive pattern of poor and interrupted parenting.
I have been in my present post of Family Services Manager for nine years, managing a busy city based resource, and community based workers. Several of the parents with whom we work, have themselves been in local authority care at some point in their life. This has highlighted for me the potential generational cycle of poor parenting, and the ultimate cost of this both to children emotionally and the local authority financially.
The study focuses on the early therapeutic interventions with young children and their parents that is undertaken at the family centre. Throughout the study the parent is referred to as ‘she’, as the particular case I have used involves a mother and her children. Much of the work at the centre involves both parents, and sometimes the work is undertaken with the father, as primary care giver, and children. The term ‘parent’ is used throughout to cover both parents and primary carers of children.
The centre provides a wide range of services to referrers and families. Obviously these will not all be included in detail in the study, but comprise:
Assessments
Family Support programmes
Specific parenting programmes
Supervised contact
Adult education courses
Practical learning opportunities for parents e.g. cooking, craft activities
Group work for parents
Individual counselling for parents
Community support groups
Nursery for 3 - 5 year olds
Children’s groups
Individual therapeutic play sessions
Holiday Playschemes for both children and families
Toy Library
This list is by no means exhaustive, and services are developed each term to meet the particular needs of the families attending the centre.
The primary task of the family centre, which is explored further in chapter 3, is to help families experiencing difficulties to improve the way in which they care for their children. Several differing approaches are used within the centre, depending on the specific needs of an individual family. The centre works closely in partnership with parents, encouraging and supporting parents to take their parenting role seriously, to meet the needs of their children. Trowell (1995:134) makes the distinction between what can change during short term work, in terms of parent behaviour and management skills, and the meta-conditions, ‘that is, the capacity for insight, to understand and think about what the difficulties are about, how past experiences maybe influencing the present difficulties, whether there may be difficulties in the parents’ past that link with the problems being experienced by the children.’
This suggests that although behaviour can be changed fairly quickly in the short term, the parent will need much more support to develop an insight into why they have been responding to their children in the way in which they have if long term results are to be sustained. This involves helping parents to understand, and to change their feelings towards their children. A low warmth and high criticism environment has been shown to be a predictor of disturbance in children (Pound et al. 1989, DoH:1995). Changing this environment for children necessitates changing how parents feel, both about themselves and about their children.
Bower (1995:75) writes about parents being offered purely practical solutions to problems, which parents then say they have tried, but do not work. She suggests that this demonstrates how the parents own childhood impinges on their ability to parent, ‘ This, I think, illustrates the enormous influence which parents’ own emotions and childhood experiences have on their capacity to cope with their children.’
I will set the context within which therapeutic work takes place, focusing on the holding environment that needs to be in place within the staff team in order that staff can then support families. The work that has been undertaken with one particular family will be examined, looking at the work with the parent, the parent and child together, and the individual work with the children. Although this case is obviously individual, it is indicative of the range of difficulties that many families bring with them to the centre. I hope that this study will highlight the value of early therapeutic work with young children and their families, and the potential that this work has to effect changes that are more likely to be sustained. As the work is still ongoing, it is not possible to say with certainty what the outcome will be for this family. However what I hope this study will demonstrate is the complexity of therapeutic work with young children and their families, indicating that sustainable change will take time and effort to achieve.
I believe that the earlier therapeutic intervention is offered to families experiencing difficulties, the more likely it is that sustained improvements can be made. Whilst this study will obviously not provide conclusive evidence to back my belief, I hope it will demonstrate that, for children within dysfunctional families, some early therapeutic work with the whole family can make a real difference to children’s lives.
The method of enquiry for this dissertation is qualitative, using a literature review and case study material. Padgett (1998:2) examines these naturalistic qualitative methods, noting that, ‘As such, they imply a degree of closeness and an absence of controlled conditions that stand in contrast to the distance and control of scientific studies. According to Manicas and Secord (1982), qualitative research is predicted on an “open systems” assumption where the observational context (and the observer) are part of the study itself.’
As this dissertation forms part of the MA in Therapeutic Child Care at the University of Reading, it seems important to reflect the principles inherent in this course. Much of the learning is through the study of, and personal reflection on, practice issues from the work settings of the students. My learning has therefore been enhanced by my practice opportunities and experiences, and I would hope to continue this process through use of case study material from Buddle Lane Family Centre.
In addition, as seems apparent from the literature review, there is little written about therapeutic work within family centres which focuses on the detail of how staff use themselves as an interactional tool. Yin (1989:23) gives a definition of a case study enquiry, ‘A case study is an empirical inquiry that:
investigates a contemporary phenomenon within its real-life context; when
the boundaries between phenomenon and context are not clearly evident; and in which
multiple sources of evidence are used.’
Much of the content of this dissertation is based on the very real, everyday life within the family centre. It has been through the sharing of thoughts, ideas and feelings, both at work and in my studying, that this has come together. Whitaker and Archer (1989:105) suggest that this method of sharing and communicating is indeed one of the components of the method of enquiry, ‘For practitioner-researchers to talk over their experiences with others also doing their own research helps considerably both with the task itself and in removing blocks to progress.’
Ethical issues
In using case study material, I will draw on recordings and observations made within the centre, both by my colleagues and myself. I have permission from the staff team to use material from the family centre, and I have sought and gained permission from the Local Authority to identify Buddle Lane Family Centre. This would seem to be important, both in terms of reflecting on earlier work relating to the centre, and on developing this model of work further.
Permission has not been sought from individual parents or children within this study, as my colleagues and I believe that seeking, and probably gaining, their permission would be likely to impinge on the therapeutic process. Some of the case material in question has been very painful for the parent/child to work through. I do not think it would be helpful for the individuals involved to go back over this purely for my dissertation purposes. I will also make use of my own reflections, both as a practitioner and as a manager; this too could impact on the therapeutic process within the work with the family. I have given careful consideration to the material I use which I have anonymised and adjusted sensitively in order to protect the identity of service users, without I hope losing the meaning and reality of the work.
Within this chapter I will focus on three main areas. Firstly I will set the legislative context within which family support services have developed, looking at existing literature relating to family centres in particular. Secondly I will look at work that focuses specifically on therapeutic work within family centre settings. Finally I will briefly outline the underpinning framework upon which the therapeutic work within Buddle Lane Family Centre is based, including research and work that was undertaken at the family centre during the early 80’s. Further references to this, and other literature will be made throughout the dissertation.
The development of family support services
The Children Act (DoH:1989) Schedule 2:9 states that, ‘Every local authority shall provide such family centres as they consider appropriate in relation to children within their area’. The subsequent Guidance and Regulations (1991) 2:19, 3:20 refer to Therapeutic, Community and Self-help centres, which seems to suggest a broad range of possible services. This broad based legislative framework has been reflected in the many different ‘Family Centre’ or ‘Family Support’ projects that have been launched or developed since the implementation of the Children Act (1989).
It is worth noting that following the recommendation in the Ingleby report in 1960, some children’s departments had established family advice centres, but these, ‘ did not become widespread but they served as forerunners of a means of prevention to become popular two decades later.’ (Holman1988:45)
The Department of Health (1998:1) published its findings of 43 projects that were supported under the ‘Refocusing Children’s Services Initiative’. This initiative ‘piloted and promoted new ways of supporting families with young children, especially children in need.’ The work within these projects focused on:
putting children in need at the centre of practice
intervening early to support families and pre-empt crisis
encouraging parents to support themselves and each other
providing a cost effective use of public funds
being replicable in other areas of the country
the capacity to be integrated into or complementary to the range of services offered by local authorities
The evaluation of these projects concluded that ‘the early intervention strategy works’ in the task of helping and supporting families. It further states that although early intervention is not necessarily quick or cheap, it is likely to be effective in terms of the prevention of further dysfunction, thus reducing future cost implications in supporting the child or family.
Macdonald and Roberts (1995:35) reported for Barnardo’s on effective interventions for children and their families in health, social welfare, education and child protection. Although the scope of the study carried out was broad, the findings point to a lack of clarity about the content of the intervention with recognition that there are problems with the maintenance of results. The reasons for these failures were investigated, and appeared to be ‘attributable to too narrow an approach in response to complex problems’. This seemed to be particularly relevant where there are severe or long-standing difficulties within the family impacting on relationships.
The report suggests that for outcomes to be effective and sustainable within these families, parent training in isolation is not likely to be a sufficient response. This would seem to be pertinent to many of the cases referred to the family centre where dysfunctional family systems and relationships have become established and issues are indeed complex.
As a result of the findings from ‘Child Protection: Messages from Research’ (DoH:1995) there has been a move nationally to refocus services to provide child protection within the context of family support. The Audit Commission report ‘Seen But Not Heard’ (1994:28) also highlights the need to give family support a high priority, noting that family centres should be developed as a suitable focus for this work. A more recent Department of Health report (1999) was published following the inspection of the delivery of social services based family support services. This report highlights general high levels of satisfaction from users, and notes that users were surprised that social services could be so helpful to them. The research found that many parents had been helped by the family support services both to respond more effectively to the needs of their children, and to take more control over their lives.
The report includes many positive comments about family support that takes place within family centres, ‘Family centres were offering an increasingly wide range of innovative services. They made extremely good use of scarce resources...’ (ibid:3). The research comments on work with disadvantaged groups and again services that were delivered through family centres receive positive comments, ‘Family centres generally gave the best attention to promoting the individual identity of black and minority ethnic and disabled children.’ (ibid:5)
Family Centre literature
Many of the books and articles that have been written about family centres concentrate on covering the wide range of services and activities that are offered to families. Much of what was written during the 1980’s was descriptive, promoting the work within family centres as a relatively new concept. Literature contained either details of the practical elements within the service, or evaluated a particular service. Examples of books that demonstrate this are Phelan (1983), Willmott & Mayne (1983), De’Ath (1985). Journal articles too followed a similar theme during the 1980’s as services began to develop. Examples of articles include those by DiPhillips and Elliot (1987), Downie and Forshaw (1987), Owen (1987), and Cigno (1988).
The 1990’s also saw similar literature being produced, with Warren (1991) producing a more detailed classification of family centre models. Cannan (1992) discusses policy making and implementation through case studies of family centres. She goes on to look at user empowerment, gender roles and parental involvement. Smith (1996:6) researched users views in six family projects. Her study illustrated ’the difficulty of making rigid distinctions between ‘outcome’ and ‘process’.’ Parents who were involved in the evaluation seemed to view and talk about the process in terms of what had been helpful to them rather than the particular services. This seems to be reflected in feedback from users of the family centre. What seems to be of greatest significance to parents and their children is the quality of the relationship between worker and user, and the changes that are facilitated within that working relationship.
There appears, during the 1990’s, to be a movement from looking at the content and practicalities of a family centre’s timetable to a more detailed look at the processes that take place within this structure. A study by Pithouse and Lindsell (1995:17) looked at the outcomes for families who had used family support services at a family centre in comparison with those who received a field social work service only. This two year study highlighted the improved impact and outcomes for families who had access to centre services but notes that ‘it is hoped that this small case study will add to the growing body of empirical work that seeks to identify what is both distinctive and effective about this relatively new phenomenon in the child welfare services’.
Therapeutic family support work
Although there is an existing, and expanding body of literature about therapeutic work with children and young people, there has been very little written specifically relating to therapeutic family centre or family support work. Much of what has been written seems to give a flavour of the environment that is created for ‘therapeutic’ work to be undertaken with little emphasis on the content or process of that work, ‘This family centre has been able to retain a homely atmosphere, which adds considerably to its success in engaging families in the work’ (Ryden and Smith 1998:53).
Trowell, Hodges and Leighton-Laing (1997:366), in their discussion of the work of a family centre in relation to emotional abuse also mention the ethos and ‘engagement issues’ that are important for motivation and improvement, ‘The parents reported dramatic improvements in themselves after a period of attendance at the Centre. Their symptoms of anxiety, depression and paranoid feelings reduced. It seems likely that the parents’ improvement is related to the Centre work. The parents had considerable input in individual sessions, work on parenting issues and on their own past experiences. This is likely to have improved their functioning and lessened the depression and anxiety.’
McMahon, Dacre and Vale (1997) consider the need for developing a theoretical framework for therapeutic practice within family centres, that looks more closely at how family centres respond in a helpful way to the complex situations which occur daily in practice. Parent-infant psychotherapy is discussed as a model for therapeutic practice. This model, focusing on the relationship between parent and child, and indeed worker and parent, and worker and child, will be explored further in subsequent chapters of this dissertation. The authors suggest that because of the wide ranging remit for family centre services, as a pre-requisite, it is crucial for the service to be clear about what they are doing and why, to have a good understanding of the ‘primary task’. Miller and Gwynne (1972), as cited in Ward and McMahon (1998:48) describe the primary task of an organisation as the task the unit ‘must perform in order to survive’.
The primary task within Buddle Lane Family Centre Family Centre is to help families experiencing difficulties to improve the way in which they care for their children. It would therefore seem important to take into consideration the theoretical perspectives underpinning this task. ‘If the mother’s own feelings of need as an infant were unmet, and there is not a ‘good enough’ memory to call upon, the mother is vulnerable, feels she cannot cope, then blames herself for failing.’ Pritchard (1999:249).
The family centre environment
The therapeutic work within Buddle Lane Family Centre is grounded in the concepts of ‘holding’ and ‘containment’ for both children and their carers. The term ‘holding’ was used by Winnicott to describe not only the physical holding that an infant needed but also the ‘total environment provision prior to the concept of living with.’ (Winnicott 1965:43). This is further described as a reliable, empathic provision meeting physiological needs and is viewed as a prerequisite to a secure and well-adjusted development for the child. Holding is seen to protect the infant from external disturbance, particularly at the stage where the child is totally dependent. In this way the parent, through their responsiveness to the infant, is providing ‘ego-support’, holding the child’s experiences together for him until he can begin to integrate these for himself.
Ward describes this process as, ‘The child gradually brings together (with help and holding) all of these fragmented bits and pieces of experience to the point where he can begin to hold himself together. The term ‘ego’ refers to this capacity to organise and make sense of one’s experience...’. (1998:17). Greenhalgh (1994) suggests that the concept of emotional holding relates to the way in which distressing and disturbing feelings that the child experiences can be safely held on to, managed and contained until the child is able to manage these for himself.
This links closely to Bion’s (1962) notion of ‘containment’. In a similar way to the concept of ‘holding’, Bion suggests that containment is the way in which an infant, ‘projects overwhelming feelings into the mother who receives them, holds them in her mind, and then conveys to the child the sense that the anxieties are bearable and meaningful.....after repeated experiences of this kind, the process is internalised by the growing child who begins to be more able to ‘contain’ his own anxieties.’ (Miller 1983:133). A child who repeatedly receives the feelings back from his mother (or main care giver), in a way that he can manage and accept, will emerge as emotionally separate.
Bowlby’s work in the 1940’s and 1950’s looked at the long term developmental impact of children who had been separated from their parents for long periods of time, or had experienced emotional adversity in childhood (Bowlby 1944, 1951).
This was backed up by the observations made by the Robertsons in 1952 demonstrating that attachments with primary caregivers were of crucial importance to young children. Bowlby’s concept of a ‘secure base’ appears similar to Winnicott’s ‘holding environment’, where parents provide, ‘a secure base from which a child or an adolescent can make sorties into the outside world and to which he can return knowing for sure that he will be welcomed..’ (Bowlby 1988:11). Bowlby further defines patterns of attachment, with ‘secure’ attachment providing the equivalent of a holding environment for the child, ‘the individual is confident that his parent (or parent figure) will be available, responsive and helpful should he encounter adverse or frightening situations. With this assurance he feels bold in his exploration of the world’ (ibid:124).
The concepts of holding and containment, through the development of relationships are crucial to the ethos within Buddle Lane Family Centre. There is a continuum of support whereby parents are helped to provide this for their children, while staff are supported and held in their work. This interactional, relationship based approach has been described by Winnicott (1960) who suggests that parents and children exist in relationship to each other. The feelings and behaviour of each affects the feelings and behaviour of the other, thus modifying the participation in the relationship. Rutter (1981) highlights this active and reciprocal interaction as a crucial key to secure attachment. Stern (1985) stresses the importance of parent/child interaction and the need for attunement within the relationship for the child to feel held and safe.
Bain and Barnett undertook a piece of work at Buddle Lane Family Centre in the 1980’s (Barnett 1986), which was based on an application of the principles of a similar earlier project in London in the 1970’s, overseen by Isobel Menzies-Lyth (Bain and Barnett 1980). These two projects focused on the improvements necessary within day nurseries to provide both a therapeutic and educational environment for pre-school children. Many clear ideas were put forward about how nurseries could shift their culture from group care which focused on physical well being, to more individualised care which incorporated the psychological care of the children.
Changes were made within Buddle Lane Family Centre following this report. These improvements included the commencement of work with parents, and the further use of assessment and planning to help children with their individual needs and difficulties. Bain states in her conclusion that, ‘ The change in the Devon day nursery is profound and encouraging. However there are still many unsolved problems. Perhaps these should be mentioned briefly, to underline that the process of change has not been easy, and is still going on with some major questions not yet answered.....how best to deal with highly disturbed parents....what additional training and professional help do the Family Centre staff need to best help them and their often equally disturbed children?’ (1986:84)
I hope the subsequent chapters, which describe the current therapeutic work within Buddle Lane Family Centre, may demonstrate the continued development of the service and the potential answers to these questions.
The many different individual components of work undertaken by the family centre are difficult to understand in isolation. There is a complex interweaving of the various strands of work within the centre. Families bring with them their own issues from their past, usually put firmly ‘away’, either consciously or unconsciously. Whilst there is often a desire to work with some of these issues, that desire brings with it feelings of anxiety and fear.
Staff, and managers, working with the families too have their own fears and anxieties. Are the children receiving ‘good enough’ parenting? Can the children’s emotional needs be held well enough by the worker until the parent is more able to do it? Can the parent be held well enough emotionally to help her explore and make more sense of her own past and the impact that has on her parenting? Can the child be kept in mind throughout the work? These are just some of the questions that workers ask themselves, and the management team, regularly.
In addition to the planned work with families, there is an added dimension of the day to day issues that come through the door with the family when they attend the centre. It is very difficult to remain focused on the planned work for the day when a parent arrives in a very distressed state following an incident of domestic violence, or the receipt of an eviction notice for example. While the feelings aroused in the parent may well link into the work that is taking place, the overwhelming priority can often be some of the practical advice and support linked to that particular event.
During the course of the working day with families there will be opportunity for a great deal of interaction with a family. Much of this can be, and is, planned for. However there are always incidents and events that need to be picked up and responded to immediately, without a great deal of, if any, time to process what has been observed.
Ward (1996) discusses a framework for the analysis of ‘opportunity led work’ which focuses on being clear about the primary task of the unit in order to have some clarity about the way in which an incident should be handled. This framework also involves making an, often very quick, assessment of the situation prior to responding. Within work at Buddle Lane Family Centre, debriefing sessions are held following every session of work with a family. These sessions focus on trying as a team to unravel some of the complexities within sessions. Through this interactive reflection of both what has happened with families during the session, and how and why staff have responded in a certain way, the whole team’s confidence in questioning increases. This seems to help staff to be more reflective in their own practice and more able to offer advice to, and accept challenges from each other.
Another consideration in this is of course the worker’s own perspective. Each member of staff working with families at the centre has their own background from within their own family. In their daily work with families staff will encounter issues that touch on their own emotions, consciously or unconsciously. They will encounter situations that evoke strong feelings in themselves which they may, or may not understand or be fully aware of.
Each member of staff, whilst having responsibility for particular families, will take on several different roles during the course of the working week. In addition to their co-ordinating role as the family’s named Family Support Worker, they may also be running a group for parents and/or children, doing individual work with a child and parent, and doing work with parent and child together. This can be very demanding and at times confusing. There may well be a conflict over the needs of the parent and the needs of the child. Whilst staff are clear that the child’s needs are paramount, the multiple task of working with the parent’s and the child’s needs is the reality if there are to be sustained improvements for the child.
Systems theory as discussed by Hall and Fagen (1956) notes that every part of a living system, or family system, is related so closely to every other part of the system that a change in one area brings about a change in the system. This interrelated and interconnected family system has an impact on the work within the centre. Both parents and their children have individual needs, and the family system needs to function effectively. Changes in one area will impact on another. This systemic approach can encourage and support a family to make changes to the family script (Byng-Hall 1995). Workers therefore need to get to know and understand both the individual components of the system, and the relationships within the system. Preston-Shoot and Agass (1990:53) reinforce this view, ‘..people should not be viewed as isolated units but always in a context, in a particular set of relationships in which they operate at any given time.’
All these factors highlight the enormous range of planned and unplanned incidents, contextual setting, events and feelings the worker has to manage in some way during the work with families. One of the crucial components of my role as manager of the centre is to provide a holding environment for the staff that helps to manage and contain their anxiety. Menzies Lyth in discussing the needs of staff in children’s institutions states, ‘.they need themselves to be contained in a system of meaningful attachments if they are to contain the children effectively.’ (1988:253)
The structure of the family centre changed following the work undertaken by Barnett in the 1980s ( Bain & Barnett 1980,1986). This work acknowledged that staff were indeed working with some very disturbed families. At the time the family centre was in the process of change, having formerly been a day nursery. Staff were clearly starting to spend greater amounts of time dealing with the parents problems. Barnett’s work enabled changes to take place that encouraged and facilitated the development of relationships between staff and both parents and children. One of the Social Workers who was involved during the transitional period commented that, ‘When a parent is excessively disturbed, the demands on the staff can be excessive.....These families create anxiety in all the workers concerned. If this is shared, it does help each individual to carry it.’ (Bain & Barnett 1980:83)
During the time I have been in post I have tried, with the help and support of my colleagues, to develop this work that began during the 1980s. It seemed vital that if staff were being asked to work with increasingly disturbed children and parents, they too needed some ‘holding’ to help them hold these families. In order to begin to provide a containing environment for the staff team a safe forum needs to be available. Debriefing sessions have been put in place following every Family Support session to help to enable staff to share their thoughts and concerns immediately after a session. The team have worked hard to develop this time and to use it effectively.
Through continued support, primarily from the deputy managers, staff are now able to challenge and to highlight observations of each other in addition to their observations of families. Within these debrief sessions there is an ethos of safety, tolerance of and respect for each other. Mawson (1994:69) in discussing the anxieties evoked in working with damaged children states that, ‘Before such difficult feelings can be openly explored in a group, particularly when the members work together on a day-to-day basis, it is necessary to provide conditions of safety, respect and tolerance, so that anxiety and insecurity can be contained and examined productively.’
The whole team meets monthly, with a designated part of the meeting to reflect on practice issues. There has been a tendency during these meeting to focus on the practical issues relating to children and their families, sharing information between workers. Through my own personal and professional development whilst undertaking the MA in Therapeutic Child Care, I have gained confidence in promoting this full group session as an opportunity for the team to explore the impact of the work on themselves, and the feelings engendered. It is still early days, but gradually individuals are feeling more able to share their feelings and to tolerate others feelings. I have found it particularly difficult to go with the silences! However it has felt important to allow the space for the emotional impact of the communication rather than hurrying on to get rid of the uncomfortable feeling.
Supervision too is seen as an important tool in helping to ‘hold’ staff. It has a high priority at the family centre, with all staff having regular time with their supervisor. Whilst some practical details need to be addressed during supervision, the process hinges on reflective practice. This reflection is not solely about looking back at what has happened, but is based on the process named by Searles in 1955, and developed further by Mattinson in1975.
This ‘reflection process’ is based on the processes inherent in the relationship between the client and the worker being reflected in the relationship between worker and supervisor. This builds on the assumption that there is, and should be, a relationship between worker and client, or in the case of the family centre, parent and child or children. This connects with Dockar-Drysdale’s view (1990) that it is not possible to do work of a deep, thorough and ongoing kind without considerable personal involvement.
The therapeutic process within the family centre hinges around these relationships: the supervisor/worker, the worker/parent, the worker/child and the parent/child. Many of the feelings that may originate from the child are ultimately reflected within supervision. Many of the children have poor attachments, with little experience of a parent ‘holding’ them emotionally. All staff, including the managers, need to experience supervision that both contains and extends the supervisee.
Issues of transference, where the parent’s or child’s feelings are projected on to the worker, and counter transference, the reaction or feelings that are evoked in the worker by those transferences, need to be explored. Without some understanding of their own early experiences, and the feelings that belong to the supervisor and the supervisee, it can be impossible to understand some of the communication inherent in work with families. Supervising staff need to be skilled and committed to this way of working, in order to help and support supervisees to explore the emotional aspects of their involvement with families.
For the purpose of this study one case study example will be used. Although obviously every family who uses the family centre has their own particular needs, with accompanying work designed to meet those individual needs, the case study example used is indicative of the complexities within referrals. Many of the families receiving family support services have similar levels of complex need, although their individual circumstances and backgrounds will be different.
The Smith Family was referred to the family centre by the duty Social Worker. There had been a duty visit to the home following concerns by the school that both children appeared neglected and the 5 year old was presenting behavioural difficulties in the classroom. The mother, Judy, appeared to be very depressed and unable to manage the lively behaviour of the children.
The initial referral requested parenting skills support for Judy, focusing on managing the behaviour of the children. The following family information was gained at the referral stage.
Ms. Judy Smith: Judy is a white female aged 25. She is living in temporary housing following a move from another area. She is separated from her most recent partner (father of her youngest child). She has been treated for depression and is currently taking anti-depressants. She is known to the local Social Services department,
having spent several years in local authority care. She has 2 children by different fathers, and is at present living on her own with the children.
She finds both children difficult to manage. She also finds it difficult to control her temper, and often shouts at the children.Tina Smith: Tina is 5 years old and attends the local school. There are concerns that she is likely to be excluded from school as her behaviour is disruptive and very difficult to manage. Both her mother and the school report that she is very bossy, and likes to get her own way at all times. She appears to have more than the average number of bumps and bruises. She is a loud, vocal girl who shies away from physical contact.
Joe Smith Joe is 3 years old. He does not attend any pre-school provision. He was born prematurely, and the hospital Social Worker was involved briefly following his discharge from hospital. His development subsequently was slightly delayed, although health professionals state that there are now no medical concerns about his development. He is a lively boy, with poor communication skills. He is prone to biting and screaming when he is frustrated.
Following the referral, an initial assessment was undertaken by the family centre. This took place in the family home with the purpose of clarifying both the information about the family, and the parent’s understanding of the referral. Judy Smith was contacted and a date was agreed for two Family Support Workers to visit the family at home. Two workers are used to ensure that the children can be given attention by one person whilst the other focuses on the parent. This generally avoids the children hearing, on the home visit occasion at least, information about themselves or their parent that is distressing.
During this home visit and the first few sessions at the family centre additional information relating to the family history and current circumstances was gained. Observations, questions and an ecomap (to highlight the existing support network) and genogram were used to help to unravel the picture about this family. Burnham (1986) states that the genogram can be used as an exploration of the family of origin, as a planning tool and as a therapeutic tool in a session with a family. It has certainly been useful in my work with families in not only all three of these respects, but also in helping parents to understand the inter-generational complexities of family difficulties, thus removing some of the ‘blame’ that parents deal themselves for not doing well enough.
The second stage of the referral to the family centre involved a meeting with the parent, the referring Social Worker, one of the Family Support Workers involved in the initial assessment, and myself as manager from the family centre. The purpose of the meeting was to discuss what support the family centre could offer, and to look at how Judy could be involved in the decision-making about which services they would access. While the meeting took place Tina and Joe played in an adjacent room with the other Family Support Worker who had visited them at home.
It seemed clear that whilst Judy was finding parenthood very difficult, she wanted to improve her relationship with her children. In response to the initial assessment question, ‘What do you want to change for your children?’ Judy had replied, ‘I’d like the children to have a better childhood than me. I’d like them to enjoy it and have fun.’ Her response to ‘What would you like to change for yourself?’ was, ‘I’d like to enjoy the children more. They’re hell to live with. I do like them really, but it’s so tiring and they’re so difficult I’d like to really like it. I want people to like me and to like my children too. I don’t want to be angry with the kids all the time. I don’t want them to go through what I had to.’
This seemed to be a positive starting point. Green (2000:26) states that, ‘Children can generate and offer a reparative hope in their parents who wish to parent in a better way than they feel they were parented. Whilst this may, of course, produce the opposite effect, it does seem important that the wish to be a good-enough parent is there and feeds into the therapeutic alliance.’
Judy seemed keen to begin work at the family centre. It was agreed that she and both children would attend initial sessions with their allocated Family Support Worker during the forthcoming school holidays. During that time Judy, the worker, and I would discuss and agree a programme of work for her and the children, to commence when the school holiday finished. The content of the programme would be checked with the Social Worker, who would be kept informed and involved as work progressed. This transitional period during the school holidays would hopefully enable Judy and the children to feel more comfortable in attending the family centre, and provide some instant practical support during the school break.
Judy and the children attended as planned for the 6 weeks of the school holidays. Tina and Joe were allocated places in the playscheme, which operated for 2 weeks towards the end of the holiday. Although they were lively they managed the sessions well. While they were busy and involved in the playscheme Judy had begun to talk with her Family Support Worker about her worries and concerns.
During these sessions the following programme of work was agreed:
1. Judy would have a weekly counselling session to help her, both in her own right and as a parent, explore her own past and the dysfunctional impingement on her present capacity to cope.
2. Joe would attend 3 nursery sessions each week at the family centre nursery. During this time he would have a weekly individual play session to help him make sense of what had been happening, and to find ways of communicating his feelings. A referral was also made for speech and language therapy.
3. Tina would have a weekly individual play session. It was agreed with the school that this would happen during the school day in a suitable room that the school would provide.
4. After some initial individual work Judy and Joe would attend a group at the family centre, focusing on improving the relationship between parent and child.
Within this programme, the family’s Family Support Worker would continue to provide weekly support to Judy to help her manage the practicalities of two small children. The sessions were primarily for Judy to be able to offload the difficulties of the week, and to help Judy to manage the children’s behaviour. This was done by use of the material from The Parent-Child Game, developed by Forehand and McMahon (1981) and adapted by Jenner (1992). This approach focuses on the reduction of child directive behaviour by the parent, and the increasing of child centred parenting. Judy was encouraged to decrease the amount of attention that she was giving to her children when they were doing things that annoyed her, and increase her attention when the children were compliant. This work aimed to give Judy more tools for the job of parenting whilst she looked at the underlying issues that were affecting her capacity to parent.
The Family Support Worker’s role, through supervision, was to pull together the work being undertaken, taking a co-ordinating role, to ensure that crucial information was shared, and to ensure that Tina and Joe were held in mind throughout the work. The following chapters detail some of this work that has taken place with Judy and her children.
‘...it is not necessarily what happened in the parent’s own childhood, but what they made of that experience which influences whether or not they can provide a secure base for their own children.....It suggests that to help parents achieve a coherent picture of their past may enable them to provide a better parenting experience for their own children.’ (Byng-Hall 1995:120)
Work with Judy was undertaken by the Family Support Worker in conjunction with the centre Counsellor. The counselling sessions are, as in all other counselling contexts, confidential. However there is a clear agreement within counselling sessions that any matters relating to a child’s welfare, or the parent’s capacity to protect their child remain of paramount importance. Within the agreement parents are encouraged to pass on any of this crucial information themselves, but are clear that the counsellor will share any such information with the Family Support Worker. Parents are also encouraged to share with their Family Support Worker any issues that arise during counselling that they (the parent) and the counsellor feel could be helpful in the broader picture of effecting change within the family. My role was to provide supervision for both workers.
The purpose of her individual time was to help Judy make some sense of her own past and the impact that was having on her parenting. Initially, Judy found it difficult to talk about herself. She would say. ‘This is about sorting the kids out’, suggesting that there was some ‘treatment’ the children could have that would make them better behaved, and therefore she would like them more. She spent much of her time initially at the centre complaining about their behaviour. One of the first things the Family Support Worker suggested was that there was some time at the beginning of the session that could take place out of the children’s hearing, for Judy to say what she wanted about how the children had been.
The worker was keen to give Judy time to let out her feelings about how the children were making her feel, but was not wanting to provide further reinforcement of the negative comments that the children seemed to hear on a regular basis. Judy was reminded during session times to try to contain her comments about how difficult the children had been, whilst they were with her.
Although Judy had clearly said, at the point of referral and subsequently, that she wanted to make changes and improve things for her children, she seemed reluctant to be involved in anything herself that might begin that process. She would arrive late for her counselling sessions, arrange doctor’s appointments in the middle of Family Support sessions, and generally be dismissive of the centre staff.
Through supervision the feelings evoked by Judy’s apparent lack of commitment were discussed. The workers felt both saddened and cross that they had not been able to engage with Judy as quickly as they had hoped. One of the workers had been involved in the holiday playscheme, where Judy had been given a break from the children. Talking openly about the feeling of not being ‘good enough’ to manage to engage with Judy as she would have liked to, feeling cross with Judy that she had provided some respite, and was now being pushed away, enabled us to connect back to Judy. Her unavailability seemed to link clearly to her inability to form a trusting relationship, rather than her reluctance or resistance to embark on the work.
The feelings the workers had seemed so similar to the emotions we had seen expressed by Judy. Understanding this helped both workers to continue, with perseverance, the task of building a relationship with Judy. Truax and Carkhuff (1967) identified three key features of effective therapy or counselling as ‘active empathy’, ‘non-possessive warmth’ and ‘genuineness’. Horne (2000:49) states that, ‘For many parents, the sense of shame with which they come to our services acts as a powerful reminder of the sense of “bad” or “imperfect” parent....’.
Throughout the following sessions staff tried to give Judy some positive and accepting experiences that might help her feel more contained herself. All staff who saw her, even if she arrived late, warmly welcomed Judy. If she did not arrive she was contacted to see how things were. She was always given ten minutes at the start of the session, which was her time to talk and to be listened to.
Judy began slowly to talk about her past. She told her story in a very matter of fact way, stating that although her time in care had not been good, it had made her what she was today. She added, “No-one’s going to tell me what to do any more. I don’t care what people think of me. They take me as they find me.” This appeared to be in stark contrast to what Judy had said at the time of referral. In looking at this further with the workers during supervision we realised that Judy’s words described exactly how Tina presented at school. It seemed likely that Judy was projecting her feelings onto Tina. Tina had initially been quiet at school, being very much on her own, and compliant. At the point of referral the school were saying she was disruptive and bossy, not caring if the other children liked her or not.
It became more and more clear as sessions with Judy progressed that her early childhood experiences had been traumatic, and there had been an absence of any consistent holding environment for her. Its absence had caused her to feel unsafe and extremely wary of making and sustaining relationships. Modell (1975) as cited in Shapiro and Carr (1991) states that, if the holding environment is absent the child is forced into a premature maturation, an ‘illusion of self- sufficiency’. This seemed to be what Judy was demonstrating in her sessions.
As Judy became more trusting of the workers, she began to talk about her feelings towards the children, always beginning with, “I’d never hurt them, but..”. What became very clear, as the pieces of information were fitted together was that Judy had on occasions hurt the children, and seemed to be very anxious that she might do this again. She would fluctuate between being outwardly confident, saying everything was fine, to being ‘at the end of her tether’ with the children, and wanting them ‘out of her sight’. This reminded me of the concept of the ‘false self’. ‘The False Self, if successful in its function, hides The True Self’ (Winnicott 1965: 150). Judy seemed to have developed part of herself to present as a confident mother who was able to manage things, which protected the vulnerable, scared and fragile person who was actually very frightened both for herself and for her children.
The children too were obviously clearly anxious around Judy. They kept a watchful eye on her, not moving an inch if she raised her voice to them. This, and the information from Judy increased our concern. The Family Support worker explained to Judy that we were very concerned both about her and about her ability to manage the children, and that we would be referring the case back to the duty social worker, suggesting that a Child Protection Conference needed to be called.
Judy was very angry with all the staff at the centre, and continued to show the ‘capable’ Judy whenever she could. During the period leading up to the conference, there was more evidence of Judy not protecting the children, leaving them in dangerous situations. Joe also had several minor injuries, which Judy found difficult to explain. Judy had made no attempt to hide these from us, and had continued to attend regularly.
Following a lengthy Child Protection Conference, the children were both placed on the Child Protection Register. Judy had been very upset and cross during the meeting and staff were anxious that she would not want to return to the family centre, as she seemed particularly cross with us for instigating the process. However this was not the case. Judy returned to the centre the following day. She seemed more relaxed and prepared to work with staff. She seemed to be relieved that we had really listened to what she was trying, but was frightened to say. She had not been able to contain and manage her own feelings towards the children, nor had she been able to provide a holding environment for her children. Judy’s own early experiences of being held, physically and emotionally had been poor and interrupted. It seemed important that we, the family centre, could begin to give her some security and containment that she was not able to do for herself. By holding her anxiety, and taking steps to minimise the risks to the children, I believe we made a huge step forward in the work with this family.
Hay, Leheup and Almudevar (1995) discuss a model of therapy for families where the workers become the ‘transitional family’ for the family in therapy. The role of the family centre could be described in a similar way. Not only is there consistency of approach from all the staff involved with the family, but the team offer persistent support and emotional holding for both parents and children. Britton (1983) looks further at this idea of the ‘transitional family’ which can provide a helpful, potentially corrective, emotional experience for the child (the article is based on therapy for the child). The work with Judy too is focused on providing her with a similar experience in order that she can begin to make sense of her past experiences, and use this understanding to make changes in the way in which she manages the children.
Bower (1995:83) states that, ‘To improve a difficult parent/child relationship an emotional shift in the parent is essential’. The work with Judy is ongoing, and will not be easy. For Judy to understand and respond to her children’s needs, she needs to begin to understand and make sense of events in her own life. This work continues, concurrent to the relationship work with Judy and Joe that is described in the next chapter.
‘The relationship between parents and their children is the most basic and formative of all human interactions.’ (Lipchick 1988:120)
In addition to the work undertaken during Family Support sessions, where parent and child or children attend together and an individual plan of work is drawn up (see chapter 5), group work focused on parent-child relationships is provided at the family centre. This work is based on the ideas of infant-parent psychotherapy, which is described by Fraiberg (1980). The concept of infant-parent psychotherapy suggests that symptoms in the infant are best dealt with by working with the parent and infant together rather than separately. The child’s presence not only ensures that the child is held in mind, but also allows for observation, and exploration of the parent’s feelings in a here and now situation.
Hopkins (1992) discusses this approach, particularly with very young children, suggesting that the capacity for rapid change in the relationship is a reflection of the combined flexibility of the infant and his parents. She further explores the notion that the parent’s feelings from a past relationship can sometimes be transferred to the child, preventing the parent from responding to the child’s needs. Coulter and Loughlin (1999:58) state that, ‘These past experiences may cast shadows on the relationship a mother has with her own baby and can act like a fairground mirror, reflecting back not the real baby but a distorted image of the baby’
Within this framework the family centre regularly runs a group for parents and children focused on communication and relationships. Parents are invited to join this group, which takes place for 2 hours each week for 12 weeks. As the focus of the group is about improving the relationship and communication between parent and child, each parent attends with one of their children, usually the pre-school child that they find the most difficult. Alternative childcare arrangements are made for any other children in the family.
Many of the ideas for this group have been taken from the work undertaken by Broughton, McKnight and Binney (1992) about ‘relationship play’. Additional material and exercises have been used from Manolson’s work (1992 & 1995) about the Hanen Approach, which encourages and promotes communication and connection between parent and child.
Judy was keen to join in the next group that was due to start. She thought it would be good for Joe to have some time to play, away from her and she was looking forward to talking with other parents. From past experience of the difficulties in maintaining attendance at these groups (as each week builds on the previous week’s work) we decided to visit each family at home before the group started to explain what would take place, and to listen to any fears or questions from the parents. This home visiting seems to have improved the level of attendance significantly, with 90 attendances out of a possible 96 during the last group.
The structure of the 12 weeks course is planned in advance. The group comprises 8 parents, 8 children and 4 staff. All children attending are known to the staff involved and are able to leave their parent without distress. Each session begins with the parents and children in separate rooms, joining together for the last 30 minutes of each session. The parents and staff together set the ground rules for the group, these are displayed in the room for every session. Each session has a clear format, with opening and closing rituals. Time is firmly adhered to, with the group commencing and finishing promptly, so that no parent is given more time than another in the group.
The content of each week’s group is planned in detail by staff following the previous week’s session, so any adjustments can be made in response to issues that have arisen.
The content of the parents’ sessions begins with exploring why they have come to the group, building on the initial home visit. During the subsequent weeks they will look at what, and how, they communicate with their child, and their memories of communication and relationships from their own childhood. This is often painful and very difficult, but being within a group where the feelings, if not the experiences, are usually similar is in itself a very helpful exercise. Parents no longer feel they are the only person feeling as they do, or behaving towards their children as they do.
Practical exercises are included; for practice for when the parents and children join together, for experiencing in a safe setting some of the feeling evoked in them by their children, and lastly to play and have some fun themselves! This does not happen instantly within the group, and many of our parents are very anxious about playing for themselves. Some have never really had this opportunity before, and need to feel well contained before they can engage in this new activity.
The children’s group too has a clear format. Each of the 2 staff has 4 children who they focus on and each child is given as much individual attention as possible. Activities within the group focus on improving the children’s communication skills, hopefully enabling them to help their parent tune into them more easily. Many of the children have an established pattern of gaining attention from their parent by inappropriate behaviour. Whilst the parent is busy within the group trying to discover how to communicate and relate to their child, the child too is discovering other ways of communicating with adults.
The part of the group where the parents and children join together focuses on relationship and contact games. Again these are graded, with very little physical contact such as Pass the Parcel and Ring a Roses, through to paired close contact games such as Row the Boat.
Judy and Joe attended the last group that I facilitated with 3 other staff. During the home visit prior to the group starting Judy had said that she wanted to be more comfortable with Joe. She said that being with him was hard work, he was always trying to wind her up, and she couldn’t ever get on with things. She said that she didn’t play with him, he preferred to get on with things on his own, although he always wanted her attention. She hoped that she’d get on with some of the other parents in the group, although she was anxious about starting. She also hoped Joe would “learn to talk better and not whinge so much”.
Joe left Judy happily to join the children’s group. Judy played an active role in setting the group ground rules, and in sharing why she had come to the group. During the children’s session some video film was taken of each of the children for a few minutes, and the parents (whose permission had been gained beforehand) were looking forward to seeing it the following week. Joining the children at the end of the first session, parents were asked to sit wherever their child was, and just watch them play. Judy found this very difficult, wanting to talk to the staff or another parent in the room.
When the video was shown during the second session parents were asked to watch their own child at play, and try to describe what he was doing. Some of the group were able to do this, saying thing like “He’s playing with the tractor. He’s getting cross with it....’. Judy, and some of the other parents found this much harder. Judy was able to comment positively on what other people’s children were doing but found it hard to focus on Joe without being negative, “He’s made a dreadful mess with the paint, why can’t he do it properly like the other children?” This seemed to link closely to her thoughts about herself, Judy often said she’d made a mess of things, and she just wanted to be like other parents.
As the sessions moved on Judy talked more and more about her own childhood. There had been very little physical touch, cuddles or affection. She felt she had got close to one member of staff in the children’s home, but she had left to work somewhere else. She, and other parents, said how hard it was to touch or hold her child, but she hadn’t really thought about why before. Judy really enjoyed some of the practical communication exercises within the group, which were intended to demonstrate how hard it is to be on the receiving end of something you don’t understand.
One exercise during the session involved parents being in pairs, sat back to back. Each had 20 coloured building blocks. Judy built a small construction with hers, and then had to explain what she’d done so that her partner could try to build the same construction with her bricks. This had to be carried out by word only; the construction could not be viewed by the partner. The frustration that Judy began to show when her partner could not understand her instructions, and her partners ensuing despair at not being given clear enough instructions was very evident. Only one of the pairs managed to copy the construction accurately, and this afforded plenty of discussion about the feelings that were evoked through one small example of miscommunication. Judy was able to make links between this and her expectations of Joe. She had felt very cross with her partner during the exercise, and she said that she often felt like that with Joe. She had assumed he was always “playing her up”, but commented, “He might not always understand what I’m on about. I do shout at him a lot”.
As the group progressed, Judy became more and more confident in getting close to Joe, and joining his play. He too began to tap her arm when he needed her attention, rather than screaming or throwing something. Judy, and indeed some of the other parents, thought that some of the contact games were babyish, and that the children wouldn’t like them. However the children loved them, and the parents too seemed to take pleasure from the experience they had not been able to enjoy when their child was younger. Photos were taken during some of the relationship games, so that Judy had some tangible evidence that she could hold and get close to Joe.
Hopefully the group has provided a secure base for Judy to begin to instigate and enjoy physical contact with Joe. The next stage of the work with her will be to help her provide that contact when Joe needs it, rather than when she is being encouraged to do it. Main (1986) as cited in Hopkins (1987) suggests that what has most meaning for an infant is not the amount of contact he has with his mother, but her physical accessibility in response to his initiative that matters.
‘Distressed children have the right to have their unhappiness acknowledged and their stories heard. They need someone who will listen to them, who can accept and contain the reality of the past, and free them to discover optimism in the present. Without this help they remain locked into feelings and behaviours from earlier events or circumstances, which they continue to carry into adult relationships and experiences.’ (Carroll 1998:153)
In addition to work with parents, and work on family relationships, the children too need work for themselves, in their own right. This work at the family centre focuses on play, which is widely understood in terms of young children’s learning as a child’s ‘work’. Play is the medium through which children begin to make sense of their world, and which helps a child’s inner world to develop.
Winnicott (1971) links the capacity to hold and contain the child, and the parent’s capacity to be in tune with their child, to the stages of play. His three stages of play begin with the mother’s attunement which enables her to make spaces for her child to develop as she ‘makes actual what he is ready to find’. The second stage is when the child plays alone ‘in the presence of someone else’, who can reflect back to the child what is happening in his play, helping the child to build links between the outside world and his own inner world. The child develops through make-believe or symbolic play a sense of self and a link with the outside world. The third stage involves the overlap between the child and adult in play, helping to develop a responsive relationship. Play is a way of exploring and assimilating information and experiences, which can then be integrated, allowing the child to develop more autonomy and to build on their inner world. Bruner (1983) as cited in McMahon (1992:1) states that ‘play under the control of the player gives to the child his first and the most crucial opportunity to have the courage to think, to talk and perhaps even to be himself.’
Many of the children who attend the family centre, including Tina and Joe, have not had good early experiences. Many have had limited opportunities to develop secure attachments with consistent carers. Fraiberg (1968:293) suggests that troubled children, who have not had sufficient opportunity to develop affectional bonds, are likely to experience further difficulties as they grow older. ‘These children who have never experienced love, who have never belonged to anyone, and were never attached to anyone except on the most primitive basis of food and survival, were unable in later years to bind themselves to other people, to love deeply, to experience tenderness, grief or shame to the measure that gives dimension to the human personality.’
Whilst the work with children that is undertaken at the family centre is not therapy, it is providing therapeutic support to children experiencing difficulties, and as such aims to help children to manage and make some sense of the painful things in their lives. The family centre approach to work with children is based primarily on the principles of child-centred play therapy with the basic premise that play itself is both creative and therapeutic.
West (1992), McMahon (1992), Wilson, Hendrick and Ryan (1992), and Carroll (1998) all discuss Axline’s model of client-centred, non-directive play therapy (1969, 1982) where the child is the source of his own therapeutic change in the presence of the therapist who facilitates this growth. As Dasgupta (1999:179) states, in discussing Axline’s work, ‘Non-directive play therapy allows the child to be him or herself without facing evaluation or pressure to change. The child is the source of his or her own growth and therapeutic change......During non-directive play therapy, a child can experience growth under the most favourable conditions: by playing out feelings, the child faces them, learns to control them or abandon them.’
Sometimes, however, a child may need more holding or containment than a non-directive approach can offer. In terms of providing the environment and appropriate toys and resources to meet the child’s needs, the family centre takes a more directive role. Oaklander (1978:192) in discussing the role of the therapist states that, ‘It is up to me to provide the means by which we will open doors and windows to their inner worlds.’ Additionally any child receiving therapeutic play work at the family centre may not be ready to manage having his feelings reflected back to him, as suggested in Axline’s model. He may need the worker to hold and contain those unmanageable feelings for him until he is more able to deal with these himself.
McMahon (1992:54 suggests that, ‘We must be aware of our normal desire to rescue children rather than to help them confront their pain. We must be aware too of feelings which arise out of our own past experiences. Another fear is being out of our depth and not understanding. It does not matter that we do not understand all that a child’s play may mean. The task in play therapy is not to interpret it to the child but to stay with children as they find it out for themselves.’
McMahon (1992:25) recognises that whilst all children need play, not all will need therapeutic play work, ‘ Yet some children have too much happening in their lives, separations, losses, abuse, repeated disruptions, changes of family membership and abode, changes of caretaker and attachment figures. Such events can be too great to cope with unaided.’ Therapeutic play work with Tina and Joe was agreed as part of the programme of work with the Smith family to help them to make better sense of what has already happened in their lives and, ‘...to repair or replicate the process of attachment and containment.’ (ibid:7).
A Family Support Worker at the family centre undertook the work with Joe. The work with Tina took place with me, within the school that she attends. A room at the family centre was booked for the same time every week for Joe and the Family Support Worker. It was harder for the school to find a regular time with use of the same room each week. It seemed important for Tina that the structure of the session was clear: that she knew which room she would be going to, on which day, and for how long the session would last. The school understood the importance of this, and managed to find a small room that we could use.
For both children the sessions needed clear boundaries with no interruptions to sessions and with play materials available. Sand and water play, small world play (animals, small play people, cars etc.), home corner, dolls, puppets, paints and other resources are readily available at the family centre. These play materials are chosen to match a child’s culture and race to foster the child’s recognition of and confidence and pride in their identity. Ahmed, Cheetham and Small (1986) discuss further ways in which work on identity for black children can be incorporated into practice. Brummer (1986:83) highlights that play materials for black children should include appropriate toys that ‘enable both child and worker to reflect on sameness and difference of colour.’
A check was made with the school about what resources could be provided and what needed to be taken to the room each week. Structure and consistency in the setting up of the sessions is important as a pre-requisite to building up a trusting relationship with the child. It gives the child a clear message that he is important and valued.
The pace at which work progresses with a child can be varied. Joe’s first session was very busy as the Family Support Worker’s account illustrates.
Joe rushed through the door, straight to the sand pit. There was barely time to say hello to him and goodbye to Judy. I told him he could do whatever he liked, as long as it was not dangerous. He seemed to have taken that for granted: within seconds the sand was flying everywhere. He kept turning towards me and smiling. I continued to watch. He ran to the box of animals, tipping them out on the floor, and banging them fiercely. One by one he took the animals over to the open window and hurled them outside.
During supervision the Family Support Worker and I discussed Joe’s arrival into his first session. It seemed as though Joe was giving a very clear symbolic picture of what life was like for him. Things were all over the place, like the sand, and adults had left his life suddenly. It felt as though Joe had done the same to the animals, making them leave suddenly and violently. Within the first few minutes of his first session his play was communicating very clearly to the Family Support Worker.
After two or three sessions Joe became less frantic. He was still very busy during his hour, but was no longer throwing the animals. His play was however still demonstrating his early experiences; animals and cars disappeared under furniture, and were shouted at by Joe before he hid them away. It appears that Joe needs time to tell this story through his play. As sessions continue he is beginning to look to the Family Support Worker to ‘find’ the hidden toys, suggesting that he is beginning to trust and develop a therapeutic relationship with her.
Tina, by contrast, came into her first session very quietly. She sat down on the bean bag while I explained that she could do what she wanted in the session, as long as it was not dangerous, and did not disturb other classes in the school (the proviso the school had made). She continued to look at me as I finished what I wanted to say. Her face was expressionless, so I asked her if she had understood what I had explained about the sessions. “Yep” was her reply, followed by nothing. She sat very still, just looking at me. I resisted my instinctive feeling to fill the silence, and sat, mirroring Tina’s position on the bean bag. After what seemed to me like an eternity, but was in reality a few minutes Tina spoke, “Tell me what I’ve got to do then.” Tina seemed to expect, as in all other areas of her life, to be told what to do. Her responses and behaviour, at home particularly, seemed to be reactions to what she was told to do, or not do, rather than any choice of her own. I quietly reminded her that she could do whatever she liked. She continued to sit quietly, picking up a book and flicking through the pages. I was feeling very anxious about whether Tina would settle in to these sessions, should I be more directive at this stage? I could sense Tina’s anxiety: was this a safe place to be, could she really do what she wanted?
I began to play quietly with the small farm animals that were close to where I was sitting. It felt important not to pressure her verbally into beginning to play, but she seemed so powerless. I felt that turning my focus to the toys, rather than Tina, might help her to join in. She began, after a few minutes, to play quietly beside me. I continued to play until Tina began to become more engrossed in her own play. Just before the end of the session, Tina picked up one of the soft toys, a small panda. She turned her back to me and said, “Well then, you’ll just have to come home with me. I don’t care if she says you can’t.” She turned back towards me, stuffing the panda into her pocket. I told her gently that it was fine to take the panda home with her, and I would look forward to seeing her, and the panda, again the following week. As I said this I was wondering whether the panda, or indeed Tina, would return. I had found the session very difficult.
Tina’s quietness and inactivity had been hard for me to manage. The hour seemed to last for ever, yet when it was time to go I felt that Tina was demonstrating what she might have been feeling. Maybe she needed to take some of the calmness from the session out with her, perhaps the panda was symbolic, and she wanted to take what I represented out with her. I thought carefully about what I would do if she lost the panda, or worse still, if it were destroyed. To my great relief Tina arrived the following week, clutching the panda!
Tina was quiet during her second session, but did explore the playroom, using the panda in her play. As the session drew to a close I suggested that I could keep the panda in a special place, safely until her next session. This was not solely to ensure I did not have the same levels of anxiety about whether the panda would return, but also to give Tina a clear message. The panda had been integral to her play; it had been the child in the home corner, and the ‘naughty’ panda at the farm. It felt important for me to tell Tina that I would hold the panda, which was starting to represent Tina, safely until our next session.
Tina’s anger has begun to emerge through her play. Traumatic scenes of road crashes and houses being demolished have come into her play, and we have reached the point where, as I comment on the hurt and pain of the toys injured in Tina’s accidents, she begins to rescue one toy from the debris. I am hopeful that this will continue, and that together we may be able to repair some of the early damage to Tina, to repair her hurt.
Therapeutic play work continues with these children. It has been important for me, and the Family Support Worker, to listen to what Tina and Joe have been saying, to observe their symbolic play and communication, and to take heed of the feelings evoked in us by the children’s projections. Holding and containing these feelings until the child is ready and able to manage them for himself can be exhausting work. Copley and Foryan (1997:167) recognise this stating, ‘The needs of staff who are the recipients of many felt-to-be unbearable feelings in the service of a containing approach also have to be considered.’
Therapeutic play work with children should not be undertaken by workers in isolation. It may appear simple, playing with the children or watching them play. Enabling children to explore and repair early damage is however very complex work. All staff undertaking this work at the family centre receive, in addition to their regular supervision, additional support to help them untangle their thoughts from a play session. This play work is recognised as a crucial ingredient in the work with distressed families.
Within this dissertation I have sought to examine, in some detail, the early therapeutic services provided for young children within Buddle Lane Family Centre. The development of family support, and family centre services has been explored through a literature review. This highlighted the diversity of services generally, and the focus of literature on the practical programmes within family centre work. It appeared that there is relatively little literature that focuses in any detail on therapeutic work within family centres.
The work of Barnett (1986), based on the changes that took place at Buddle Lane Family Centre during its transition from a day nursery to family centre was included in this study. Whilst there was recognition in Barnett’s work that changes in working practice had taken place, there were also questions raised about what further developments were needed for staff to be able to work effectively with disturbed parents and their equally disturbed children.
I hope the account of the current therapeutic work within the centre might highlight some of these developments, and the value of this work with both parents and their children.
The work discussed takes place within a busy setting, with staff undertaking several roles within their working day, in their quest to empower both children and their parents. This demands flexibility from workers with an ability to hold the children in mind, whilst working with the often conflicting needs of the children and their parents. Staff too need support in exploring the issues of transference and counter transference in the therapeutic relationship. There is an expectation that staff try to hold or contain feelings for both parents and their children until they are more ready to manage these for themselves. For staff to manage this responsibility the holding environment needs to be mirrored in the way in which staff are treated.
The support systems for staff within the family centre aim to provide some of this containment for staff, in order that they can safely provide this for the families. I hope the continuum of holding is apparent in this work: the managers provide this environment for staff, who in turn provide it for parents (and their children) until they are able to hold and contain painful feelings. It is important that the child too is held safely during the process, whilst the parent is not able to do this adequately.
The Smith family case study has been used to illustrate both the holding relationships within this work, and the complexities of work with families. Examples of the work with the parent, the parent and child together, and the children individually have been used to demonstrate the therapeutic work undertaken with a family.
I hope the work with Judy may have demonstrated the need to involve, empower and work in partnership with parents, to make significant improvements for the children. Bower (1995:75) as quoted in chapter 1, comments on the, ‘enormous influence which parent’s own emotions and childhood experiences have on their capacity to cope with their children.’ If this work is not undertaken it is much more difficult to make and sustain significant improvements for the children. I would suggest.that work which provides parents with a secure holding environment for themselves is likely to be beneficial in helping them to provide better experiences for their children.
Work with Judy and Joe has focused on the parent-child relationship. This too is a crucial part of the work within the family centre, providing a secure base for the parent to build or repair their relationship with their child. As work with the parent takes place it is often easy for her to lose sight of the child, as she focuses on her own issues. This relationship work helps the parent tune in to her child, increasing physical holding and intimacy, thus providing a stepping stone in repairing insecure attachments.
The work with the children in this study is continuing. What I hope the work to date will have demonstrated is that children are able to communicate through their play. As staff working with these children, who have experienced often repeated and damaging separations or traumas, we need to be able to listen to this communication. Examples of the work with Tina and Joe indicate the beginning of a relationship with the worker through which the child is, ‘given the opportunity to play out his accumulated feelings of tension, frustration, insecurity, aggression, fear, bewilderment, confusion.’ (Axline 1969:16). Therapeutic play work is an effective way of helping children to both understand themselves, and to be understood by others.
Early therapeutic intervention with young children and their families can be an effective tool in diversionary planning for children, preventing the child’s transition into substitute care. Preventative models of work as described by Widerstrom et.al. (1997:290) are often viewed as difficult to describe and to justify as, ’they seek to avert a problem that has not yet occurred.’ However early intervention has been researched (DoH 1998, 1999) and found to be effective.
Early intervention, with therapeutic work for both parents and children, has the potential to make a real difference to children’s lives, which ultimately must contribute to more sustained positive outcomes for children.
Ahmed S., Cheetham J. & Small J. (eds.) (1986) Social Work with Black Children and their Families, London: Batsford
Aldgate J. & Simmonds J (eds.) (1988) Direct Work with Children, London: Batsford/BAAF
Audit Commission (1994) Seen But Not Heard, London: HMSO
Axline V. (1969) Play Therapy, New York: Ballantine Books
Axline V. (1982) Entering the child’s world via the play experience. In: Landreth G. (ed.) (1982) Play Therapy: Dynamics of the Process of Counselling Children, Landreth, Illinois: Charles C Thomas
Bain A. & Barnett L. (1980) ‘The design of a day care system in a nursery setting for children under five.’, London: Tavistock Institute of Human Relations (TIHR) Document No. 2T347
Bain A. & Barnett L. (1986) The Design of a Day Care System in a Nursery Setting for Children under Five, Part 1 Abridged version of Bain & Barnett 1980; Part 2 Application of Principles in Devon: TIHR Occasional Paper no. 8
Bion W. (1962) Learning from Experience, London: Heinemann
Boston M. & Szur R. (eds.) (1990) Psychotherapy with Severely Deprived Children, London: Karnac
Bower M. (1995) in Trowell J. & Bower M. eds. (1995) Psychodynamic family therapy with parents and under-5s, London: Routledge
Bowlby J. (1944) Forty four juvenile thieves: Their characteristics and home life, International Journal of Psychoanalysis 25: 19-52, 107-127
Bowlby J. (1951) Maternal Care and Mental Health (2nd Ed.), Monograph Series 2, Geneva: World Health Organisation
Bowlby J. (1988) A Secure Base. Clinical Applications of Attachment Theory, London: Routledge
Brazelton T. & Barnard K. (eds.) (1986) Touch New York: International Universities Press
Britton R. (1983) Breakdown and reconstitution of the family circle, in Boston M. & Szur R. eds. (1990) Psychotherapy with Severely Deprived Children, London: Karnac
Broughton S, McKnight I & Binney V. (1992) Relationship Play Manual, Doncaster Child & Adolescent mental Health Service, Depy. of Child & Family Psychiatry
Brummer N. (1988) White Social Workers/Black Children: Issues of Identity, in Aldgate J. & Simmonds J (eds.) (1988) Direct Work with Children, London: Batsford/BAAF
Bruner J. (1983) ‘The Functions of Play’, address to the Pre-school Playgroups association conference at Llandudno, in Contact, December
Burnham J. (1986) Family Therapy, London: Tavistock Publications
Byng-Hall J. (1995) Rewriting Family Scripts, New York: Guilford
Cannon C. (1992) Changing Families. Changing Welfare, Hemel Hempstead: Harvester Wheatsheaf
Carroll J. (1998) Introduction to Therapeutic Play, Oxford: Blackwell
Cigno K. (1988) Consumers view of a Family Centre Drop In, British Journal of Social Work 18: 361-375
Copley B. & Forryan B. (1997) Therapeutic Work with Children and Young People, London: Cassell
Coulter H. & Loughlin E. (1999) ‘Synergy of verbal and non-verbal therapies in the treatment of mother-infant relationships’ British Journal of Psychotherapy 16 (1)
Dasgupta C. (1999) Listening to children through play, in Milner P. & Carolin B. (eds.) (1999) Time to listen to children, London: Routledge
De’Ath E. (1985) Self help & Family Centres, London: National Children’s Bureau
Department of Health (1989) Children Act 1989, London: HMSO
Department of Health (1991) Children Act 1989. Guidance and Regulations Volume 2: Family Support, Day Care and Educational Provision for Young Children, London: HMSO
Department of Health (1995) Child Protection - Messages from Research, London: HMSO
Department of Health (1998) Families in Focus: Evaluation of the department of Health’s Refocusing Children’s Services Initiative, London: HMSO
Department of Health (1999) Getting Family Support Right. Inspection of The Delivery of Family Support Services, London: HMSO
DiPhillips N. & Elliot V. (1987) The Amersham Family Centre, Child Abuse Review- Spring 1 (5) 13-16
Dockar Drysdale B. (1990) The Provision of Primary Experience Winnicottian Work with Children and Adolescents, London: Free Association
Downie A. & Forshaw P. (1987) Family Centres, Practice 2 : 140-147
Forehand R. & McMahon R. (1981) Helping the Non-Compliant Child: A Clinicians Guide to Parent Training, New York: Guilford
Fraiberg S. (1968) The Magic Years, London: Methuen
Fraiberg S. (1980) Clinical studies in Infant Mental Health: The First Year of Life, London: Tavistock
Green V. (2000) in Tsiantis J. (Senior ed.) Therapeutic space for re-creating the child in the mind of the parents, London: Karnac
Greenhalgh P. (1994) Emotional Growth and Learning, London: Routledge
Hall A. & Fagen R. (1956) Definition of a system General Systems Yearbook 1: 18-28
Hay J., Leheup R. & Almudevar M. (1995) Family therapy with ‘invisible families’ British Journal of Social Work 68: 125-133
Holman R. (1988) Putting Families First. Prevention and Childcare: a study of prevention by statutory and voluntary agencies, Basingstoke: Macmillan
Hopkins J. (1987) Failure of the holding relationship: some effects of physical rejection on the child’s attachment and on his inner experience, Journal of Child Psychotherapy 13 (1): 5-13
Hopkins J. (1992) Infant-Parent Psychotherapy, Journal of Child Psychotherapy18 (1):5-17
Horne A. (2000) Keeping the Child in Mind. In Tsiantis J. (senior ed.) (2000) Work with Parents: Psychoanalytic Psychotherapy with Children and Adolescents, London: Karnac
Ingleby Report (1960) Report of the Committee on Children and Young Persons, London: HMSO
Jenner S. (1992) The assessment and treatment of parenting skills and deficits: within the framework of child protection, ACPC Newsletter 14: 228 233
Landreth G. (ed.) (1982) Play Therapy: Dynamics of the Process of Counselling Children, Landreth, Illinois: Charles C Thomas
Lipchik E. (1988) Treatment of Disturbed Parent-Child relationships, in Troubled relationships, Nunnally E., Chilman C. & Cox F. eds. (1988) California, London, New Delhi: Sage
Macdonald G. & Roberts H. (1995) What works in the Early Years - Effective interventions for children and their families in health, social welfare, education and child protection, Ilford: Barnardos
Main M. (1986) Parental aversion to physical contact with the infant: stability, consequences and reasons, in Brazelton T. & Barnard K. (eds.) (1986) Touch New York: International Universities Press
Manicas P. & Secord P. (1982) Implications for psychology of the new philosophy of science, American Psychologist 38: 390-413
Manolson A. (1992) It Takes Two to Talk. A Parent’s Guide to Helping Children Communicate, Toronto: Hanen
Manolson A., Ward B., Dodington N. (1995) You Make The Difference, Toronto: Hanen
Mattinson J.(1975) The Reflection Process in Casework Supervision, London: Institute of Marital Studies, The Tavistock Institute of Human Relations
Mawson C. (1994) Containing anxiety in work with damaged children, in Obholzer A. & Zagier Roberts V. (Eds.)(1994) The unconscious at work, London: Routledge
McMahon L. (1992) The Handbook of Play Therapy, London : Routledge
McMahon L., Dacre V. & Vale J. (1997) Reflection and Emotional Containment: Therapeutic Work in Family Centres, Early Child Development and Care 132: 21-31
Menzies - Lyth I. (1988) Containing anxiety in institutions: Selected essays volume 1, London: Free Association Books
Miller E. & Gwynne G. (1972) A Life Apart: A Pilot Study of residential Institutions for the Physically Handicapped and the Young Chronic Sick, London: Tavistock Institute
Miller S. (1983) Glossary in Boston M. & Szur R. (eds.) Psychotherapy with Severely Deprived Children, London: Tavistock Institute
Milner P. & Carolin B. (eds.) (1999) Time to listen to children, London: Routledge
Modell A. (1975) ‘A narcissistic defence against affects and the illusion of self sufficiency’, International Journal of Psychology 56: 275-282
Nunnally E., Chilman C. & Cox F. eds. (1988) Troubled relationships, London: Sage
Oaklander V. (1978) Windows to Our Children, Utah: Real People Press
Obholzer A. & Zagier Roberts V. (eds.) (1994) The unconscious at work, London & New York: Routledge
Owen G. (1987) Love Thy Neighbourhood Family Centre, Community Care 15th October: 20-22
Padgett D.(1998) Qualitative Methods in Social Work Research, London: Sage
Phelan J. (1983) Family Centres: A study, London: The Children’s Society
Pithouse A. & Lindsell S. (1995) Specialist referred family centre and field social work: a comparative study of user views on service impact and outcome, Research, Policy and Planning 13:13-18
Pound A., Puckering C., Cox T. & Mills M. (1989) ‘The impact of maternal depression on young children’, British Journal of Psychotherapy 5: 241-252
Preston-Shoot M. & Agass D. (1990) Making Sense of Social Work, London: Macmillan
Pritchard P. (1999) Helping parents with severe parenting difficulties, Community Practitioner 72: 248-251
Robertson J. & J. (1952) A two year old goes to hospital (film), London: Tavistock
Rutter M. (1981) Maternal Deprivation Reassessed, Harmondsworth: Penguin
Ryden N. & Smith F. (1998) A family centre in practice, Practice vol. 10: 1, 45-54
Searles H. (1955) ‘The Informational value of the supervisor’s Emotional Experience’ in Collected papers on Schizophrenia and Related Subjects, London: Hogarth Press
Shapiro E. & Carr A. (1991) Lost in Familiar Places, New Haven & London: Yale University Press
Smith T. (1996) Family Centres - bringing up young children, London: HMSO
Stern D. (1985) The Interpersonal World of the Infant, New York: Basic Books
Trowell J. (1995) The Munroe Young Family Centre, in Trowell J. & Bower M. (Eds.) (1995) The Emotional Needs of Young Children and their Families, London & New York: Routledge
Trowell J. & Bower M. (eds.) (1995) The Emotional Needs of Young Children and their Families, London & New York: Routledge
Trowell J., Hodges S. & Leighton-Laing J. (1997) Emotional Abuse: The Work of a Family Centre, Child Abuse Review 6: 357-369
Truax C. & Carkhuff R. (1967) Towards Effective Counselling and Psychotherapy, Chicago: Aldine
Tsiantis J., Boethious S., Hallerfors B., Horne A. & Tischler L (eds.)(2000) Work with Parents: Psychotherapy with Children and Adolescents, London: Karnac
Ward A. (1996) Opportunity Led Work: 2. The Framework, Social Work Education vol 15 no 3: 40-59
Ward A. (1998) The inner world and its implications, in Ward A., McMahon L. (eds.) (1998) Intuition is not Enough, London: Routledge
Ward A., McMahon L. (eds.) (1998) Intuition is not Enough, London: Routledge
Warren C. (1991) Family Centres in The Children Act 1989, London: HMSO
West J. (1992) Child-Centred Play Therapy, London: Edward Arnold
Whitaker D. & Archer J. (1989) Study 9. Research by Social Workers. Capitalizing on Experience, London: CCETSW
Widerstrom A., Mowder B. & Sandall S. (1997) Infant Development and Risk, Baltimore: Paul H. Brookes Pub. Co.
Willmott P. & Mayne S. (1983) Families at the Centre, London: Bedford Square Press NCVO
Wilson K., Kendrick P. & Ryan V. (1992) Play Therapy: A Non-directive Approach for Children and Adolescents, London: Bailliere Tindall
Winnicott D.W. (1960) The theory of the Parent-Infant Relationship, in The Maturational Processes and the Facilitating Environment, London: Karnac
Winnicott D.W. (1965) The Maturational Processes and the Facilitating Environment, London: Karnac
Winnicott D.W. (1971) Playing and Reality, London: Tavistock
Yin R. (1989) Case study research. Design and methods, USA: Sage Publications
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