The Development of a Clinical Programme and Therapeutic Practice in a Children’s Home and Residential Special School

When I established Appletree in 1995 I had recently returned from a three-year Masters Course resident at a Treatment Centre in Connecticut USA. I had learnt much but what I particularly wanted to ensure was that

  • our children accessed therapy
  • therapy was supported by the care and teaching teams
  • all interactions with the children were thoughtful and therapeutic.

By therapeutic I mean that the interaction’s purpose is to help meet the children’s emotional and psychological needs rather than the needs of the adult or the system/organisation.

All of the children at Appletree have been severely abused, neglected and traumatised. Although they are aged between six and eleven years on admission, their emotional and psychological needs are those of a baby or toddler. They need to experience unconditional love, understanding and care which we expect to give a very young child. They also need the security of firm boundaries and sensitive explanation about how important it is for us to keep them safe. Once they have experienced this we can then begin to help them to make choices and grow into more age-appropriate experiences.

I initially worked with a clinical psychologist who was part of the team who looked at referral papers and then advised on individual programmes for the children. Although we considered her working individually with children we decided that this would better be done by a team. I approached the NSPCC as specialists in helping abused and neglected children. They provided our children with individual therapy for ten years and when the team closed the therapists chose to continue to work with us. They continue to have regular, expert supervision and external consultation.

It was soon clear that one of the most important issues to address is that therapy can not exist in a vacuum. Team members could not just drop children for therapy and expect some ‘magic wand’ to be wafted by the therapist and the child to be ‘fixed’. In fact, often a healthy therapeutic journey would include a child getting more angry, upset or distressed. We adopted the approach that the NSPCC therapist would work with the child’s keyworker in the same way that they work with birth, adoptive or foster carers. They would talk regularly and share ideas and information to work in partnership to help their child. Where appropriate, they would work together to promote attachment.

This is effective but the child has a team of carers and whilst the key worker is important, all carers need to be able to interact therapeutically. We therefore decided that the NSPCC therapists would offer consultation to the whole team of carers to help share information, ideas and agree how individual children would most helpfully be treated. These discussions inform the children’s placement and action plans.

There are, however, issues which arise within teams which do not relate to children’s individual therapy. There can be disagreements about how to interpret and respond to a child’s difficult behaviour. ‘Splitting’ between adults is common but requires a forum where it can be identified and a united response agreed. Certain children can and do arouse strong feelings with individual team members. This is understandable but again an exploration of this in a safe environment is vital.

We agreed that our psychologists would provide this safe environment. They meet with all of our care, teaching, management and facilities teams away from the children. These clinical consultations were initially viewed with varying degrees of suspicion. There was a general wary-ness which at its most extreme was expressed as “I don’t need my head examined”. Gradually over the years a culture developed which began to value these opportunities to explore difficult issues in a supportive and non-judgemental way. A couple of indicators of our success were the momentous day when the management team arrived for consultation only to find we had got the wrong date and we went ahead with consultation anyway. The second was when our clinical psychologist was off sick and the first agenda item on the care team meeting was “Who’s going to do our clinical now then”?

The final part of our clinical programme is the extension of our training to include regular day-long sessions led by our psychologists and our children’s therapists. These ensure that all the team members learn about the theory of child psychological development, attachment and trauma symptoms. This can then inform and underpin their practice and their consultation sessions.

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