The Manual – How to do it: A Therapeutic Approach to Foster and Social care.
For over 25 years I have been developing a way of training foster carers and social care workers to live and work with the young people in their care using a therapeutic and healing approach. This is my first attempt to set down this approach in the hope that it will useful to carers and to others taking up the task of training and supporting the carers. My usual way to begin a training programme is to set out the deliberately few principal theories that I consider essential to the task and then the skills and interventions that relate to these theories. But mostly I emphasise that while the effective therapist may eventually have a handy toolbox of useful theories and skills, it is crucially the presence of the therapist that makes the difference. It is the professional and creative use of the helper’s self that facilitates the person being helped to become him or herself. This approach is more about ‘being with’ rather than ‘doing to’. It also crucially assumes that there may be nothing inherently wrong with the person being helped, something that must be diagnosed and fixed. Rather it assumes that the child or grownup has been wronged in some way, such as missing out on some critical care or having been seriously neglected or damaged. It is perhaps more likely that he or she is possibly acting out that neglect and damage in the unconscious hope of the behaviour being understood as communication, a cry for help. Too often the behaviour is seen as the problem to be stopped and reacted to, rather than understood and responded to.
The first thing that usually dawns on the carers who begin to get this approach in training and who are open to it, is that they must change first before the young person will begin to feel safe enough to change. Once this change process has begun it encourages more change on the part of the carer and a therapeutic healing process begins which can be permanent rather than temporary as when behaviour is simply manipulated or suppressed (and its causes) by rewards and punishments. What may have been a miserable and conflictual relationship becomes a therapeutic alliance and a source of great satisfaction.
Although my professional practice has mostly been with children, young people and the people who care for them, I also believe that hurting and deprived people of all ages and abilities in cared-for situations or otherwise would benefit from this approach as it is based on respect and love and confidence in the ability of everyone to heal and change. I look forward to hearing from social carers in these settings when they try this road, “the one less traveled by”, especially if they find, like Robert Frost, “that has made all the difference”.
Historical Background to the Approach
It has long been the tradition for foster carers and residential child care workers to look after the physical needs of the children and to take the child to an ‘expert’ when they needed therapeutic or psychological support. However, the tradition of progressive therapeutic communities (see Ward, A…below) while always accepting that some children and young people may need specialist help, have mostly worked from the principle that the relationship between the child and their most trusted adult is where the most therapeutic work can take place. Barbara Dockar-Drysdale, the Dublin-born founder of the Mulberry Bush School in the UK, argued that children who had primary deficits in their lives needed these deficits to be met, and not just talked about, and that this could only be done by the committed adults they were living with. She was supported in this approach by her mentor and friend, the distinguished paediatrician and child psychoanalyst Donald Winnicott who referred child patients from his day clinic to the Mulberry Bush where they could have their emotional and physical needs met in a 24/7 therapeutic milieu. John Whitwell offers a valuable website (see Usefull Links below). John was the director of the Cotswold Therapeutic Community during the 10 years Dockar-Drysdale was their external Consultant Psychotherapist. Subsequently, when he became the CEO of Integrated Services Programme (ISP), perhaps the first independent fostering service in the UK pursuing a therapeutic approach which put the carer at the centre of the therapeutic task, his ambition “was to develop the therapeutic understanding of the staff and carers and to apply the therapeutic child care principles (Dockar-Drysdale, 1990, Winnicott, 1984) which we practiced at the Cotswold Community.”
John was very supportive on the setting up in Ireland in 2003 of a therapeutic foster care training programme in Kilkenny. Rose Brophy, Principal Social Worker, and I were concerned about the lack of suitable places for children moving successfully on from Sacre Coeur, the therapeutic High Support Unit for children at St Bernard’s Children’s Services in Fethard, Co Tipperary where I was the external child care consultant. These children had enjoyed a good standard of high-quality therapeutic care which needed to be continued and not reversed. An Open Evening was advertised to take place in a local hotel which attracted many existing carers as well as prospective carers. Part of the package was that I would be on-call and available to carers on a consultancy basic. That training ran for several years before it was curtailed and the special allowance for therapeutic foster carers withdrawn for financial reasons.
The Carlow College (St Patrick’s) Certificate in Therapeutic Foster Care
The Kilkenny training was succeeded on a more regional basis in 2014 by the setting up of the Carlow College (St Patricks) Certificate in Therapeutic Foster Care Course in partnership with TUSLA, the Child & Family Agency and St Bernard’s Children’s’ Services. Sixteen training days (10.30am to 1.30pm) were offered by the staff team of the MA in Therapeutic Child Care Course (now the MA in Leadership in Therapeutic Child and Social Care Course) at a venue in Callan, Co Kilkenny, as it was more convenient to the foster carers. Staff from St Bernards (most of whom were formerly Sacre Coeur staff and so were very experienced and trained in the therapeutic approach) provided a 24/7 support and advice service. Subsequent carers have consistently stressed how invaluable having this support was, access to people who understood and had ‘been there’, who were always at the end of the phone and available to call out and be involved in the process.
An outline of the average course day is necessary to illustrate the historical and professional links to therapeutic community practice and to professional therapy training. The course was designed to have the same, though modified, structure, philosophy and content of the MA (LTC&SC) course which uniquely encouraged students to make links between their personal, professional and academic lives.
Ground-rules of strict confidentiality are agreed beforehand, and the carers, now students for the day, have agreed that each course day setting is less a training event and more a clinical and professional workshop. The day begins with an Opening Round where the carers are invited to share how they are (feeling) that morning. If, however someone is very distressed and in crisis, which is very rare, they will be responded to in the ‘here and now’ rather than wait until sometime later. Many carers in the Opening Round share that they are upset about something but can hold it until later that morning. The course strives to be a safe holding environment with the staff team modelling this ethos and as the students learn to hold their anxiety and feelings of panic, so will they be able to emotionally hold and contain the children in their care.
Colleen Macintosh Hill, a former colleague at Sacre Coeur and current colleague on the MA (LTC&SC) at Carlow College, and I then offer a class on the theory timetabled for that day. This can be sometimes very light-hearted and sometimes heavy depending on the subject matter, but participation and awkward questions are very much welcomed, as are situations from real life past or present.
After a generous break during which there is often much noisy sharing, we divide (the average course number is 22) into two groups. One group is led by psychotherapist and group facilitator Dorothy Casey, who leads the Experiential Class on the MA (LTC&SC) at Carlow College. She will gently encourage the students to share what it is like for them being foster carers. In this safe and confidential setting, they can be real and fully express their feelings, both positive and negative. They are not allowed to talk about the children but only about how caring for the children affects them. Common negative themes have been their childhoods and how they have been affected by them, the stress and pain involved in facilitating traumatic access meetings, feeling unsupported and not professional by the ‘real’ professionals and their fear of losing the children if they complain and are perceived to be troublesome. What seems to keep many of them going is the love they have for the children and the attachments they make.
Meanwhile, in another room Colleen and I invite the students to offer situations that they are struggling with. Sometimes they receive help and advice from fellow students and always support. Sometimes, as a psychotherapist, I may offer them a clinical intervention that I know has worked in similar circumstances. Sometimes Colleen may share some interventions from her Sacre Coeur experience. The crucial thing is that they are given something concrete to take home and try. We enjoy hearing how successful some of these interventions are and if they are generously shared in the Opening Round the following week, it seems to give courage and confidence to others. If interventions don’t work, we can try something else. However, some simple interventions, such as having a bravely requested treat like a few chocolate fingers unconditionally on the kitchen table when an anxiously attached child returns from school, seem to work wonders.
We end the work with a Closing Meeting and the students are invited to check-out. We call it out health check to see if they are OK to drive back to their families. Once a student asked us “What if we aren’t OK to go?” We replied that we would look after them until they were.
The only exceptions to the rules of confidentiality, besides the obvious one of needing to report dangerous or concerning behaviour, are these:
- If I offer a clinical intervention to a student which may affect the care plan of the child or children in question I need to share that intervention with the manager of the therapeutic support team. I am always open to conversations with all professionally concerned.
- Sometimes a student/carer may be in an intractable situation and with their permission I will take that to the TUSLA principle fostering social worker.
This training has run successfully for the last five years and the students receive their certificates at the college Graduation Ceremony in November. I have also presented a much modified six session training version on five occasions to TUSLA foster carers attached to the North Dublin Region. On these occasions I offer a seventh training day for the social and link workers: the carers always ask that the social workers and the link workers are given the same information they have been given. Presently, I consult to three residential child care centres, two TUSLA, one voluntary, who are working from a therapeutic community model. I continue to work occasionally as a psychotherapist with individual children who may be struggling in foster care or residential care settings.
What will follow in subsequent chapters will be the principle theories we teach from. For simplicity I divide them into the following schools: Humanistic, which is all about feelings, grief and loss, how we allow children to grieve and to safely let go sometimes toxic feelings and memories in order to recover; Behaviour/Cognitive, learning how to communicate from the thinking part of our personality, our Ego or Adult, to the functioning Ego or Adult in the youngest child or the stroppiest teenager. Too often we talk down to the Child part of their personality from the Critical Parent of ours. When we are being rational, we can also help them to correct faulty thinking, perhaps that they are too stupid or unlovable. Finally, the Psychodynamic School which requires us to always ask what is behind the behaviour or below the surface. In this school we meet Bowlby and Attachment Theory, learn how broken attachments can be repaired and more complicatedly, how children who never attached in the first place can be facilitated to do so, thanks to the priceless contribution of Winnicott to this process.
For the last ten years or more, overarching these traditional schools, are the new and exciting insights and findings coming from Allan Schore and his colleagues. They are proposing that the effects on the developing brain of the neglected and traumatised child can influence his or her neurological wiring and the capacity to self-regulate. The good news is that this damage can be significantly reversed given a carer who is emotionally available to the child (or person) willing to be attuned to the person rather than to the behaviour. This approach can make such an immediate difference and that is where I will continue in Chapter 2. While waiting for me to write it, the following papers are available to read now:
Modern Attachment Theory: The Central Role of Affect Regulation in Development and Treatment Judith R. Schore Æ Allan N. Schore
Right-Brain Affect Regulation An Essential Mechanism of Development, Trauma, Dissociation, and Psychotherapy Allan N. Schore
Finally, there are many excellent YouTube videos of Allan Schore speaking and making his theories very accessible.
Bowlby, J. (1988) A Secure Base London: Routledge
Dockar-Drysdale B (1990) The Provision of Primary Experience London: Free Association Books
Ward, A, Kasinki, K, Pooley, J (Eds.) 2003 Therapeutic Communities for Children and Young People London: Jessica Kingsley
Winnicott DW (1986) Home is where we start from London: Penquin