MODELS IN THERAPEUTIC WORK WITH TRAUMATIZED CHILDREN - PART 1 - PATRICK TOMLINSON (2014)

Date added: 08/10/20

Introduction

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

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

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

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

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

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

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

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

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

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

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

From this example, it can be seen how all these aspects of the infant’s environment are connected to his overall sense of well-being. It would be no use to have emotional needs met within the context of an environment that is not being well-managed. The consequences of the lack of management may lead to a deterioration that would cause stress for the parents and potential hazards in the environment, which would impact negatively on the infant. The same applies to organizations.  It could be argued that effective management provides the container in which therapy can take place………..It is crucial in the residential treatment of traumatized children that the whole organization and every activity within it are aligned to this work………Confirming the importance of this, Canham (1998, p.69) argued, “...the whole way the organization functions is the basis for the possibility of an introjective identification.” The children will internalize not only the relationships they are most directly involved with but also the way the whole organization functions. (The above section has been adapted from Barton et al., 2012, p.47)

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

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

Whether Darwin precisely said that or not it is an important point. Models must be alive and adaptive – they must be open systems and have feedback loops, so they can receive the information they need from all parts of the system. In other words, a model can never become a fixed entity, as one part of the system changes other parts must adapt. It must continuously evolve. For example, a change in the external environment, politically, economically, or professionally will require an adaptation. As with evolution, those that survive are the most adaptive.

 

 

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

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

Barton, S., Gonzalez, R. and Tomlinson, P. (2012) Therapeutic Residential Care for Children and Young People: An Attachment and Trauma-informed Model for Practice, London and Philadelphia: Jessica Kingsley Publishers

Bowlby, J. (1969). Attachment. Attachment and Loss: Vol. 1. Loss. New York: Basic Books

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

Keenan, K.A. (2006) ‘Food Glorious Food: An Exploration of the Issues of Anxiety and its Containment for Children and Adults Surrounding Food and Mealtimes in a Residential Therapeutic Setting.’ MA Dissertation, Planned Environment Therapy Trust  

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

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

Andrew Collie - Organizational Consultant, England - Thanks for this Patrick. Child care without a model is child care without concern for the child. 

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