Reflections on the therapeutic relationship in residential provision at a specialist college.
Residential care can be a very deliberate act of therapy done by professionals in a professional setting. It may be a kind of loving but often it has to look like a kind of hating, and the key word is not treatment or cure but rather it is survival. If you survive then the child has a chance to grow and become something like the person he or she would have been if the untoward environmental breakdown had not brought disaster. D.W.Winnicott
This portfolio was my final piece of work for my MSc in Psycosocial Studies and represents some of my work as a Shared Lives Provider (SLP) for a specialist residential college which works with young people between 16 and 25 with complex behaviour and learning difficulties and disabilities, including autistic spectrum conditions and developmental delay.
Many students at the college have experienced environmental failure in early life and their difficulties are often associated with trauma and abuse.
The college offers a three year programme with a practical skills curriculum which aims to be both educational and therapeutic. The college offers both day and residential provision with most students being residential. Residential students live off site as part of the local community, either in team houses or living with Shared Lives Providers (SLP). In a Shared Lives placement providers share their home with up to three students.
Shared Lives has the potential to provide a setting for residential care that can minimize the intrusiveness of more formal and institutional approaches to caring which have become dominant (Schwartz, 1997, p3). Increasingly the trend in society is ‘to see care instrumentally and contractually’ (Smith, 2009, p15), with systems put in place which depersonalise care and discourage individual relationships (ibid, p32). Our work as SLPs does not escape entirely from this managerial approach with its conceptually flawed attempts to improve provision by increasing bureaucracy and regulation. However, at the core of our work is a concept of care as ‘essentially a relational and ethical endeavour ‘ (ibid, p165). In this endeavour striving for certainty and predictability is not sustainable or desirable (ibid, p174). In this portfolio I want to demonstrate a professional approach to residential care which can embrace the ambivalence and uncertainty of moral responsibility (Bauman, 2000, p10) and which can contribute to a practitioner based knowledge of residential care.
The first part of the portfolio is an essay on a paper by D.W.Winnicott, ‘Residential Care as Therapy’. This provides a theoretical base for a relational, therapeutic and developmental approach to care. Work in residential care can be emotionally draining and overwhelming (Barton, Gonzalez and Tomlinson, 2012). The work is also often under-appreciated, even within our own organisation (Smith, 2009). Winnicott provides a thought provoking and life affirming theoretical base which can keep us in touch with the fact that we are engaged in an important and meaningful task. We need this base to build confidence in our own professional integrity and competence. The danger is that without a strong theoretical base the sense of professional competence becomes invested in bureaucratic compliance rather than in emotional engagement (Smith, 2009).
The essay is followed by two case studies in the form of reflective diaries. They are both reflections on separation, describing how we ended our work with two students, one who lived with us for 18 months, the other for two years. I have written about these two students in other essays submitted for modules in my MSc Psychosocial Studies and so including the two endings in this portfolio adds a sense of completion for me to the whole degree. The two cases are nevertheless quite distinct and both illustrate various themes discussed in the essay. Endings may be one of the most emotionally complex aspects of residential care to manage thoughtfully and with integrity (Haigh, 2013). For me this further justifies the specific focus in the case studies in this portfolio.
Students’ names have been changed in the case studies and care has been taken to ensure unnecessary detail has not been disclosed in order to preserve anonymity and ensure confidentiality in relation to students and work environment. The intention in using case studies is to reflect on my experience in relation to the theoretical framework set out in the essay in order to develop insight, effectiveness and resilience in my work. The focus is on my own professional development and in no way did this compromise the quality of the care the students received. As I live and work with them, the students may have been more or less aware of my study activity. Having risk assessed making this more overt and transparent and asking for consent, it was felt that this would risk unsettling them and compromise the quality of care which I provide. In order to improve the quality of care I am able to offer I need to explore the complex and ambivalent feelings that arise in my work, feelings which the students should not be concerned about or feel responsible for. The decision not to share this work with the students was therefore seen as a necessary therapeutic and professional boundary to maintain.
RESIDENTIAL CARE AS THERAPY
In this essay I want to consider how a residential placement with a shared lives provider (SLP) at a special needs college can be thought of as a therapeutic intervention. I will draw on the work of D.W. Winnicott to provide a theoretical framework for this discussion. Reviewing his 1970 paper ‘Residential Care as Therapy’ I will elaborate on key concepts he provides for thinking about therapeutic approaches to our work with students.
Winnicott delivered this paper as a lecture at the end of his life; he died a few months later. In this lecture he was able to draw on a lifetime’s work, focusing his thoughts on the therapeutic value of residential care. This makes it a good starting point to explore his writings in relation to the task of shared lives provision.
Winnicott applied his psychoanalytic thinking to wider societal issues and his work has been particularly influential in the realm of residential child care. His continuing relevance in this field is apparent in the current practice, theory and research that continues to draw on his insights. (Haigh, 2013; Barton, Gonzalez and Tomlinson, 2012; Reeves, 2012; Palereti and Berti, 2009; Tuber, 2008; Morgan and Hollins, 2006).
Winnicott’s focus on the mother – infant relationship emphasised the importance of the environment for healthy early infant development and he advocated the need for a planned 24 hour a day therapeutic setting to address the problems arising from early environmental failure (Barton, Gonzalez and Tomlinson, 2012).
It is not easy to quantify this therapeutic environment and attempts at measuring outcomes of specific interventions miss the significance of ‘the thousands of unnoticed informal interactions … that occur in the daily routines’ (Palereti and Berti 2009, p1081). These interactions are informed by our attitudes and capacities as residential workers and Winnicott’s work is a great resource for thinking about and developing these.
The college is governed by a trust. The trust’s vision states that we want our world to be one in which ‘each individual experiences meaningful relationships with universe, earth and people and has the potential to shape their own future’ . This vision encompasses our environment in the broadest sense and refers to our creative expression within it.
Winnicott sees the establishment of meaningful relationships as a developmental achievement (Winnicott, 1986) and he discusses the individual’s creative expression in relation with their environment (Winnicott, 1990). In this sense an exploration of Winnicott’s work can provide a methodological approach to grounding the vision in everyday experience.
Winnicott’s paper (1970) sets out certain essential features required in residential provision: reliability, holding, non-moralistic attitude, no gratitude necessary and survival.
Winnicott says that reliability should be experienced as a general attitude in the home. He hastens to add that this should not be a mechanical reliability, but a human one. It will therefore be relative because human beings are unreliable.
A degree of unreliability is to be expected in Shared Lives because students live within the ordinary lives of the providers. This requires some discussion of professionalism. The professional attitude is an idealised version of ourselves (Winnicott, 1957) which can be maintained within strict boundaries of time and space. The professional attitude can also become a defence against vulnerability which reduces ones capacity to meet new situations with openness (1957). In Shared Lives we cannot avoid bringing our vulnerability and our unreliability into our work, yet we still have to maintain a degree of professionalism. We ‘have to examine the things that come naturally in the home setting in order that we may do these things deliberately and adapt what we do economically to the special needs of the individual (students) or meet special situations as they arise’ (Winnicott, 1970, p192). In examining the things, doing them deliberately and adapting them, lies what Winnicott would call the professional orientation of therapeutic residential work.
Graduated failure of adaptation plays an important part in Winnicott’s concept of the ‘good enough’ mother. The infant can start to meet the deficiencies with mental activity and thereby ‘turns a good enough environment into a perfect environment’ (Winnicott, 1949, p245). Our adaptations to the student in SLP settings may at first need to be near absolute, but should soon become relative, requiring the student to make use of an inevitable element of unreliability for their own development. The inability to do this would be a counter-indication for SLP placement (Winnicott, 1951). Winnicott acknowledges that the task may be impossible for residential care where there has been significant disruption in early infancy (Winnicott, 1970).
The rationale for providing reliability is that many children coming to residential care will have grown up in chaotic and unpredictable environments. He characterises them as confused, disorganised, disorientated, restless, lacking in concentration and perseverance. As Tuber (2008) points out, these symptoms closely fit those we would associate with ADHD today and Winnicott’s work might encourage us to take environmental factors into account as well as neurophysiological ones in the etiology of this condition (p65). Winnicott suggests that these symptoms are actually ‘hiding something which could be called a true self ‘ (Winnicott, 1970, p194). In an unpredictable environment the child will have expected trauma and therefore will have hidden ‘this sacred central area of the personality’. Winnicott describes the unthinkable, intolerable anxiety that the child experiences if this central core of the self is wounded in terms of ‘falling forever, going to pieces’, an anxiety that remains with them as a hidden threat.
In Winnicott’s theory, where the true self is hidden it is defensively protected by a false self. This can take more or less extreme forms. The true self may be entirely hidden to the person themselves, or may lead a secret life protected by the false self. At a less extreme level he describes a false self that ‘has as its main concern a search for conditions which will make it possible for the true self to come into its own’ (Winnicott, 1960a, p143). This further develops the rationale for reliability as therapy: the true self can emerge in a safe and predictable environment.
Another level at which a false self can operate and which is pertinent to our work as SLPs, is that of the false self built on idealisation and identification with significant others. In this sense we may find ourselves mirrored in the false self of a student who uses us as a role model. At times we must guard ourselves from the seductive pleasure of being idealised. We may also experience this as highly intrusive and need to protect ourselves with clear boundaries.
Winnicott also mentions the healthy manifestation of a false self which is sometimes called for simply to function in society. This aspect of fitting in can be an important achievement for students. In healthy circumstances this can be considered to be the social self, without which the true self would not survive in society (Grolnick, 1990, p71). However, Winnicott makes it clear that only the expression of the true self gives a person a feeling of authenticity and vitality (Tuber 2008, p62).
The graduated failure of adaptation mentioned above must be graduated in the sense that it provides acceptable experiences of limitation from which feelings of authenticity and vitality can recover. In terms of the mother and baby, if the mother is too unreliable, the baby’s mental activity becomes an anxious ‘mood forecast’ which tries to assess when it is safe to be spontaneous and when personal needs must be withdrawn to protect the true self (Winnicott, 1967, p113). The true self is then hidden and the false self has the task both of hiding the true self and of complying with the demands of the outside world (Winnicott, 1955, p147) Violence is always latent in false self compliance and sometimes will become manifest (Winnicott, 1970, p194). In terms of Shared Lives provision we must be aware that an overly controlling rule-bound residential setting which achieves anxious compliance would not be therapeutic. A human and relative reliability is called for, not a mechanical one. It requires an openness towards the student’s spontaneous gesture and this requires vulnerability within our professionalism.
There is great hope and optimism in Winnicott’s concluding thoughts on reliability:
In residential care reliability of a human kind can in the course of time undo quite a severe sense of unpredictability and a great deal of the therapy of residential care can be stated in these terms (Winnicott 1970, p194).
Winnicott uses this idea to further discuss reliability as therapy. The baby is first held in the mother’s womb, then in her arms, where gradually a relationship between ‘me’ and ‘not-me’ can develop (Winnicott, 1955, 1958). The child is then held within the family and wider society. Where home life does not provide the necessary stability society will have to intervene. In the last resort, when things go badly, the prison cell provides the holding environment (Winnicott, 1946).
When things go well the infant can become integrated as an individual with a sense of an inner and an outer world. This can only happen in the context of a good- enough environment characterised by the love of the mother which can identify with the infant and feel that adaptation to its needs are worthwhile.
Winnicott suggests that the moment of integration, which he calls an I AM moment, is a raw moment in which ‘the new individual feels infinitely exposed’. It can only be risked in the arms of a reliable mother (Winnicott, 1955, p164).
If in a child’s past a good- enough holding environment was disrupted, it will be the task of residential therapy to provide a reliable environment where this can be re-discovered (Winnicott, 1970). The residential care will need to provide ‘a kind of loving’, but in Winnicott love is never sentimental. This love is practically demonstrated in the ‘willingness to hold the … unintegrated self, and to meet aggression with firmness … and to meet hatred with hatred, appropriate and under control’ (Winnicott, 1963a, p216). The openness and vulnerability mentioned above are not without boundaries and confrontation.
The child or student is seeking something that feels real and for this he needs to experience the carer’s ability to hate objectively (Winnicott, 1947). That is to say that if what he feels to be unacceptable about himself is not acknowledged, then being loved does not feel real (Phillips, 2007).
Winnicott pays homage to the life work of John Bowlby who drew attention to ‘the sacredness of the early holding situation’ (Winnicott, 1970, p195). Bowlby’s concept of the secure base is another way of thinking about a holding environment and can contribute to a conceptualisation of residential care as therapy:
A central feature of my concept of parenting (is)the provision by both parents of 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 when he gets there, nourished physically and emotionally, comforted if distressed, reassured if frightened. In essence this role is one of being available, ready to respond when called upon to encourage and perhaps assist, but to intervene actively only when clearly necessary (Bowlby, 1988, p11).
This is all very pertinent, but in residential therapy the emotional nourishment will also need to include appropriately meeting the aggression and hatred of the unintegrated individual as mentioned previously. Winnicott reminds us to expect symptoms to get worse when a child or young person regains hope. Stealing or violence, he suggests, are expressions of hope. This is a thought Winnicott develops in his paper ‘The Anti-Social Tendency’ (1956). The child has been deprived of early good experience through environmental failure and seeks to reclaim what has been lost. The legitimate claim of the infant becomes provocative anti-social behaviour that seeks management, by which Winnicott means ‘a going to meet and match the moment of hope’ (1956, p106). By thinking of antisocial behaviour in these developmental terms we may be able to provide a good enough holding environment which avoids vindictive retaliation.
Winnicott states quite categorically that residential therapy can have nothing to do with a moralistic attitude. Diagnosis must replace moral judgement and must be grounded in an understanding of the cause of behaviour. Bruno Bettelheim, another pioneer of the therapeutic environment (1955), entreats us to imaginatively enter into the child or student’s experience and ask ourselves what would make us act in the way they are, and what would bring relief? (Bettelheim, 1987). Winnicott acknowledges that the residential worker will have a moral sense of right and wrong, as will the student, whose moral sense may be fiercely punitive. Bettelheim explores the dynamics of moralistic judgements in terms of transference. We may work out of a false sense of superiority as defence against our anxieties. He suggests that people may be drawn to care work precisely to convince themselves of their goodness. Such workers will seek out the positive transferences from students but will not be able to cope when, through negative transference, they are seen as selfish monsters. Many youngsters in need of residential care will not be able to believe in the good intentions of others and will need to test them to breaking point. Only by surviving their destructive impulses can trust develop and this may take months if not years (Meyer, 2010).
Winnicott describes the essential developmental achievement of ‘using objects’ for the baby as follows:
Hullo object! I destroyed you. I love you. You have value for me because of your survival of my destruction of you. While I am loving you, I am all the time destroying you in (unconscious) fantasy (Winnicott 1971, p90).
The psychoanalytic concept of ‘using an object’ does not mean exploiting or manipulating the other, quite the opposite. The capacity to use objects arises developmentally when a baby ‘has internalised enough good object experiences that she actually has created a respect for the sanctity of the other’ (Tuber, 2008, p88). When there has been a failure in this development the task of residential therapy will be arduous. Winnicott’s argument is that there is nothing to be gained from labelling the behaviours associated with this as morally bad, but that we must seek to understand the behaviour as legitimate in the light of the child or student’s individual history. Winnicott’s point of view is ‘that morality develops naturally in the child without having to be inculcated’ (Rodman, 2003, p276). Therapeutic residential provision needs to provide experiences through which the disruption of this natural development can be restored.
Winnicott is pragmatic about the use of punishment as a response to the ‘inconvenience’ of troublesome behaviour and how it appears to the outside world. It is a reactionary response and not a therapeutic one. However, Winnicott seems unconcerned about a limited use of punishment, suggesting that children can tolerate it and even feel some relief because the punishment they are expecting is so much worse than what they get. What they expect is vindictive punishment, and Winnicott is quite categorical that vindictiveness has no place in residential care. He nevertheless acknowledges that in this work everybody will have a vindictive moment. This needs to be seen for what it is: unavoidable human failure, but not therapy.
Because it is normal to have vindictive and angry feelings, particularly when we have been personally attacked, working without recourse to punishment can be a radical and challenging idea (McLellan, 2010). However, punishment can be seen as not just un-therapeutic but also counterproductive. Where children have been unfairly and harshly punished in the past, further punishment is likely to trigger further anger and resentment. (Barton, Gonzalez and Tomlinson, 2012). Docker-Drysdale (1953) argues that this hampers the potential development of a capacity of concern for others. Essential for this development is the experience of making reparation in respect of personal guilt. Winnicott considers this to be ‘one of the most important steps in the development of the healthy human being’ (1948, p91). Simplistic punishment and reward systems may achieve compliance, but will do so by reinforcing a concern for oneself and do little more than develop the capacity to avoid punishment. The therapeutic approach would be to help students understand that there are consequences to their behaviour and to allow them to find ways to make their own reparation. (Barton, Gonzalez and Tomlinson, 2012). In this approach we must remain thoughtful about distinguishing boundaries from punishment and particularly to heed our own vindictive feelings when they arise (Ward, 2006).
No Gratitude Necessary
In a therapeutic relationship one would not expect gratitude and we should even be suspicious of it. This is a professional attitude based on the normal parenting experience where children can take for granted everything that goes well. As Winnicott says, the ‘parent who expects a baby to be grateful is looking for something false’ (1970, p195). The expectation of gratitude is a demand for compliance and as such will be the expression of a false self. The true experience of gratitude is a developmental achievement and we may well have the pleasant experience of receiving it in our work. Winnicott does not ask us to ‘turn down a gift’, but insists that this is not what should motivate us in our work. Related to this is Bettelheim’s insight, mentioned earlier, that care workers may be drawn to their work to convince themselves of their own goodness, needing the appreciation and the gratitude of those they try to help.
Rather than expect gratitude, we should expect children or students in our care to become a nuisance. We would expect antisocial behaviour. We might call it ‘challenging behaviour’ nowadays, or, in more extreme cases it might be diagnosed as conduct disorder (Ward, 2012). What is important is to keep in mind that this behaviour has a communicative function (Morgan and Hollins, 2006). Winnicott sees ‘nuisance’ as an encouraging sign, an indication that ‘a significant step in the humanising process has been achieved’ (Tuber, 2008, p181). Stealing and destructiveness, two aspects of the antisocial tendency, are manifestations of hope (Winnicott, 1956). The therapeutic response lies in the stability of the environment where the child or student can rediscover reliable care as well as firm holding which ‘will stand the strain resulting from impulsive behaviour’ (ibid, p107).
Winnicott acknowledges that this strain will at times seem intolerable. At those times our job is not ‘to cure the symptoms or to preach morality or to offer bribes’ (1970, p196) but to survive. By this he means not only to live through it and to avoid getting damaged oneself, but also not to be ‘provoked into vindictiveness’. Students may then be surprised by the experience of ‘still being regarded warmly and even affectionately despite their horribly challenging behaviours’ (Ward, 2006, p11). Those who survive can be “of use”, which is to say they can ‘contribute to the genuinely new life of the subject, nutriment that is not the result of projection, not self-manufactured’ (Rodman, 2003, p376).
Winnicott relates all antisocial behaviour to what would normally occur in early childhood in the home: ‘if the home can stand up to all the child can do to disrupt it, he settles down to play’ (1946, p99). In characterising the essence of a therapeutic environment, Haigh, drawing on Winnicott, suggests that a ‘play space’ can be re-created in which ‘new behaviours, explorations, emotions, relationships and ideas’ can arise ‘with a richness, intensity and variety which would be impossible to devise in other therapies’ (2013, p9). Play, for Winnicott, is the route to self-discovery and self-development. A prerequisite for this is belief in the environment which arises out of the experience of continuity and reliability (Phillips, 2007). If we survive disruption a more wholesome relationship can develop which may even feature an element of gratitude. However, there will be failures and we will have to survive these as well in order to ‘enjoy the occasional success’ (Winnicott, 1970, p196).
Our job will often be to provide essential experiences of continuity and reliability that were disastrously disrupted in early childhood. This will allow the person to become more like the person they would have been had there been no breakdown. Winnicott has faith in natural processes of development which will reassert themselves in a non-intrusive holding environment. This approach could be misunderstood as a bland ‘kind of therapeutic quietism’ (Phillips, 2007, p52), but it should be clear that what is needed is a full and genuine encounter. This ‘may be a kind of loving but often it has to look like a kind of hating’ (Winnicott, 1970, p196). Winnicott emphasises again that survival is the key word, not treatment or cure. It is more a matter of ‘being with’ than of ‘doing to’. This may constitute quite a radical shift from professional authority to authentic relationship, but it is only through the experience of real relationships that a true sense of personal agency can develop (Haigh, 2013, p13).
The college caters for a diverse and wide range of students. Not all students will have experienced the environmental breakdown in their early years that Winnicott addresses in his work, but a significant number do fit this description. Winnicott’s work in residential care originated during the second world war when he was involved in the evacuation of children from London. His responsibility was to oversee the placement of those more troubled children who could not be placed with host families. Shared Lives Provision offers precisely a family environment for students. There is quite a lot of diversity within these placements, some of which would be unsuitable for the more troubled students. There are also some students who cannot be held in a SLP’s home and who are placed in team homes where staff work in shifts. Shared Lives provision therefore does differ from the residential care that Winnicott was writing about. (However, in a particularly troublesome case, described in his paper Hate in the countertransference (1947), Winnicott found it necessary to take the boy in question into his own home.) Residential care can be provided in various settings, but wherever we encounter the problems associated with early environmental breakdown Winnicott’s ‘essential features’, grounded in his developmental psychology, will be valid. These essential features focus our attention on the qualities we need to develop as SLP’s to survive our encounters with the young people in our care and to enable them to move on in their lives.
REFLECTIONS ON SEPARATION: LEO
You must have a proportion of failures, and this again is something you have to survive in order to enjoy the occasional success. (Winnicott, 1970, p196)
The following is an account of how we brought our work with a student, Leo, who lived with us for 18 months us, to a close.
Leo had stolen money from us on several occasions. This caused ongoing tension in the household as we had to be continuously vigilant, both on our own behalf and on behalf of the two other students living in the house. The first time he stole from us was after he had been with us for three months and, following Winnicott (1956), we tried to think about this theft as a manifestation of hope: was Leo starting to feel safe enough with us that he could seek to reclaim, in a displaced manner, something of his early good experience that might have been lost through environmental failure?
Although the ongoing theft provoked strong, vindictive feelings in us, our weekly supervision helped us maintain an open and inquiring attitude towards Leo. In our firm but non-punitive response we held to the hope that our ongoing relationship with Leo would allow him to develop his capacity of concern for others, an essential developmental step which would depend on Leo’s experience of making reparation in respect of personal guilt (Winnicott, 1960b). We understood that this would take time. However, a year later we found that in this respect little progress had been made.
In the end it was not specifically because of his stealing that we considered ending Leo’s placement with us. We were becoming increasingly frustrated with living with a young man who refused to engage with us. In Winnicott’s terms (1960a) we did not feel we were meeting Leo’s ‘true self’ even after providing a reliable environment for over a year. His resistance to any engagement or development was deeply puzzling. All we could do was to accommodate him and to negotiate the minimal level of respect we needed from him to tolerate him as a guest in our house. We felt that our approach varied from looking after a lad who was lost and bewildered to confronting a lad who was lazy and selfish. When we confronted, relations rapidly deteriorated.
A sense of self-preservation started to play a significant part in our thinking about ending our work with Leo as tensions within the household were at times running high. However, we also increasingly thought we were doing Leo a disservice by allowing the situation to carry on. Leo was approaching the final term of his last year at college and was in no way engaged in preparing for his transition into supported living. We felt that a change of placement in the summer term would demand engagement from Leo.
What we wanted to avoid was a crisis and breakdown in his placement and we were increasingly concerned that this could happen. We therefore considered giving the required six weeks’ notice at the end of the spring half term for Leo to leave our household after the Easter holiday.
After the half term holiday we had a conversation with Leo and asked him whether he had thought about his placement with us over half term. He said he hadn’t. We said that we had given it a lot of thought and that we were not willing to continue with him if things were going to carry on the way they had been. We also explained that we are required to give six weeks’ notice if we want a student to leave and that we had given this notice for him to leave our house at the end of term. We then said it was up to him to make us change our minds.
We followed this up with a meeting with his personal tutor and our residential manager the next day. Leo engaged well in both these meetings and was able to articulate and reflect on some of his difficulties and the tensions these give rise to in our household. Leo had come back in a positive frame of mind and seemed willing and able to meet our basic expectations for students in our house. He also acknowledged that he had often been unable to keep this up, that he could lose confidence and that it was then hard for him to pick himself up again. We said that we could support him through these low moods but that we wouldn’t put up with the disrespect and disengagement we had experienced the previous half term.
Our residential manager and Leo’s personal tutor made it clear that there was unlikely to be any other suitable residential placement available for Leo if he was not able to make it work with us. This meant that the commitment we were asking him to make was likely to constitute a decision about finishing his full year at college.
In our meeting with Leo there was something he said that really struck me. Most days during the previous half term he had refused or been unable to get up in time to go to college. He would often be more than an hour late, sometimes not leaving the house until midday. My partner had started to bring him up a cup of coffee to help him get going. During the meeting he said that often the cup of coffee made him feel worse. He felt he didn’t deserve it because he was ‘such a lazy c*** staying in bed’.
As mentioned above, our approach varies from looking after a lad who is lost and bewildered to confronting a lad who is lazy and selfish. When we are ‘looking after’ Leo by bringing him a cup of coffee we fail to acknowledge the contempt he feels for himself. We must guard ourselves from becoming sentimental about our task. In his seminal paper ‘Hate in the Counter-Transference’ Winnicott says: ‘It seems doubtful whether a human child as he develops is capable of tolerating the full extent of his own hate in a sentimental environment. He needs hate to hate’ (1947, p202). Confrontation was exactly what Leo needed. In retrospect initiating the process to end Leo’s placement looks like a planned intervention, but our desperation was very genuine. I believe that the emotional charge of the situation made it better than a planned intervention because it draws Leo into feelings of concern, a capacity to feel guilty and the need to make some reparation (Winnicott, 1960b). This is exactly the developmental step he needs to take.
There is an interesting parallel between Leo’s situation and the case Winnicott describes in ‘Hate in the Counter-Transference’ (1947). This is the case of the boy Winnicott and his wife took into their own home because he could not be contained anywhere else. Winnicott describes the feelings of hate engendered in him by the boy. At times of crisis he would put the boy outside the front door and tell him that what had happened had made him hate him. Outside there was a bell which the boy could ring and when he rang it he would be let back in and no more would be said about what had happened. Although he did see this as an intervention that would help the boy progress, he gives greater importance to the fact that this allowed him to tolerate the situation ‘without losing (his) temper and without every now and again murdering (the boy)’ (ibid, p200).
The words of hate and the act of putting the boy outside is what provides the containment he needs. Telling Leo that his behaviour is intolerable for us and in giving college the six weeks’ notice to terminate his placement may similarly provide the containment that Leo needs. Paradoxically placing the child outside the most obvious container, his home, is containment and not abandonment of the boy (Tuber 2008, p166). In our situation, taking the first steps towards terminating his placement tells Leo he cannot take us entirely for granted. We would hope that this might provoke a sense of belonging in him which he finds worth making a commitment towards.
In the discussion of Winnicott’s concepts of reliability and holding I stated that the need for openness and vulnerability does not preclude the provision of firm boundaries and confrontation. Bion’s concept of containment provides further insight into the capacities one needs to develop to manage this balancing act.
In discussing Bion’s concept of containment Hinshelwood (1999) considers three varieties of container in inter-personal relationships in which there is a dynamic relationship of mutual influencing between the container (in this context, the SLP) and the contained (the student). A rigid container refuses to respond to the intrusion and therefore the content of that intrusion, the contained, cannot find form or meaning. At the other end of the spectrum, a fragile container loses its own form because it is overwhelmed by the intrusion. In both these cases the experience for the child/student is that its own state of mind is not tolerable. A flexible container can respond to the intrusion. It is influenced by the intrusion, feels it and to some extent suffers it, but it maintains thoughtfulness. If I as a practitioner can allow myself to experience the intrusion as a direct communication, be unsettled by it but nevertheless maintain thoughtfulness, something of this will be available for the student in my care to make use of. Not only can the original anxiety, modified by having been contained, be introjected, but the object capable of containing and thinking about the original anxiety can also be introjected (Segal, 1975, quoted in Hinshelwood, 2001).
The everyday experience is that sometimes we are too rigid, sometimes we are too fragile and therefore sometimes we fail. It is important to recognize the failure for what it is and to bring thoughtfulness to the feelings that these failures elicit. The more we can do that, the more we become the flexible container that can maintain a balanced mind.
Leo is not willing to participate in the activities and the running of our household and chooses not to contribute to our life together. He lives with us like a lodger who takes from us what he finds convenient.
He has managed well over the last few weeks to get to college on time, to put the bins out on Thursdays and to cook something for himself twice a week. On request, he once did some household shopping.
I have been feeling quite resentful that Leo has been told that there is not likely to be another suitable placement for him if things don’t work out with us. He has been able to demonstrate a commitment to being at college and therefore the difficulties in our house should not jeopardize him finishing his year at college.
He will not learn anything from being with us for another term. We have had the patience to wait for him to take some initiative, making use of his placement with us, but this has not happened. He needs to move into a new placement for his final term where he is required to take responsibility for his own living environment so that he goes some way towards preparation for supported living after college. We have confirmed our notice with the conviction that a solution will be found once we force the situation. Crisis focuses attention and resources better than urgency. This is probably due to the fact that living with feelings of precariousness, doubt and frustration is a recognised part of the job and working with these feelings is part of the therapeutic work in residential care.
Underlying our decision to end our work with Leo is our frustration of not being able to connect with him. In our latest supervision we managed to say something about a fear he must live with, a fear of failure, a fear of his own aggression… we are not sure. There is an emptiness about the lad. He often makes me feel pathetic in my inability to engage with him. Is this the counter-transference at work? Is this a communication about his feelings about himself. The sadness is that there is clearly some deep disturbance in his ability to relate and we have failed in reaching this.
I feel relieved that he will go and that we have been able to be clear and decisive about this. Nevertheless, I am also torn by feelings of betrayal because I can also see Leo as a lost and bewildered little boy who needs to be held, who might be able to take the next developmental step if he felt secure. Maybe I must accept that I am simply not that person, that there is something about me that makes him feel radically insecure. I often feel that when I speak to him, Leo responds as if he is under threat of my greater verbal ability, thrown into a panic that he might not understand, trying to extract himself from the encounter as quickly as possible. The times he has spoken to me he keeps his flow going so that he cannot be interrupted because that would land him back into the unpredictability of conversation.
In a meeting with Leo, his personal tutor and our residential manager we discussed what Leo would need in his last term. This needed to be distinguished from what he wants and demands.
In the meeting Leo made quite a turnaround, saying he wasn’t ready for independence yet. He said he wanted to return to living with his parents after leaving college and that he wanted to take things in small steps. He acknowledged his need to be looked after.
We experienced this as a slap in the face as he has rejected so much of the support we have offered him. However, the acknowledgement that he would not manage on his own may be an achievement in itself, and if he has been forced to admit this to himself by us asking him to leave our house then this has been an meaningful intervention.
Our work with Leo has been to adapt to his needs as best we understood them and trust that a capacity for reciprocal relationship would develop out of this. Our experience is still that he takes, but cannot give. As discussed in the essay, we would not expect gratitude, but we would have expected the development of some concern and respect for the other. This would be an important developmental step. This has not happened and leaves us feeling that we have failed in our work with him.
However, since confirming that Leo will have to leave our house, there have been moments where we noticed expressions of gratitude from him. In a footnote in The Piggle, Winnicott (1989, p96) says: ‘Gratitude implies acceptance of separateness, of the reality principle, a fruit of disillusionment.’ Maybe ending our work with Leo is exactly what he needs developmentally. Maybe only in ending our work can the fruit of it be seen.
A participant in our reflective practice group offered me a way of thinking about Leo’s development from a complexity perspective. Paraphrasing his contribution: Our work does not constitute a step in a linear developmental process but is an ‘invasion’ into the established patterns of Leo’s actions and relationships. At what point he may be nudged into a new configuration is unpredictable. The nudge of ending our work with him may be a last resort, but also feels like the most constructive intervention we can make at this point in time.
REFLECTIONS ON SEPARATION: CHLOE
The practicalities of leaving are just as important. It represents loss of a very important attachment, and the successful negotiation of it is a crucial part of the whole process. Leaving is usually the most significant loss a member will experience while having the full depth of therapeutic support available: it might be the first chance to “do it well” and be something to learn and grow from. Communities often arrange it with rituals and gifts, but the real sense of sadness and loss need to be experienced, for it is by being fully aware of the pain of detachment that the intensity and meaning of the attachment before can be understood and “taken inside”. It usually involves a mixture of anger, desolation, yearning and hope: the end of something very important, but also the beginning of the rest of life starting in a different place. (Haigh 2013, p8)
Chloe is in her second year at the college and lived with us from the beginning.
Chloe was adopted when she was two and a half. She was removed from her birth parents at 16 months and had 9 different placements before adoption. Chloe’s rejection of her adoptive parents when she was 17 led to social services arranging an alternative residential care placement for her. She came to us with her adoptive parents at the beginning of term, but after having spent the summer living away from them in her alternative placement.
During the first year we were able to provide her with the continuity and reliability she needed. She grew in confidence and independence. We talked about family and adoption. It became clear that she presented very differently at home with her parents than with us during term time. With us she was happy and thriving at college, at home she became withdrawn and temperamental, with her mum taking the brunt of her anger and resentment.
Thanks to the possibility of meeting and working with her parents during the year it was possible by the end of her first year for Chloe to go home for the holidays, with some support and respite care in place.
During her first year we also supported Chloe through some emotionally disastrous romantic relationships which brought to the surface her deep anxieties around abandonment.
Also during this first year, we became grandparents. This happened to be in parallel with Chloe’s older birth sister having a second child. Chloe does not see this sister and only re-established contact with her during her first year with us. We found we had to establish clear boundaries to protect this aspect of our personal life from Chloe’s intrusiveness.
Chloe’s self expression became less split in her second year and we started to see a bit more of the behaviours mum had described to us in our house too. She was envious of the attention a new first year student in our house was getting and was struggling to find her place within the new constellation of our household.
Chloe developed a strong attachment to us. This provided her with the secure base she needed to thrive at college and to make some reparation with her adoptive family. However, we started to question how long we could tolerate her intrusiveness as a couple. At first I felt uncomfortable at the thought of abandoning her in her third year, given her traumatic early experiences. Yet increasingly it became clear to me that an experience of well-managed and thoughtful separation was exactly what she needed even though the process would be distressing and painful.
At a preparatory meeting for her annual review in January we put it to her that it would be worth thinking about a different residential placement for her third year. She was upset, she cried and could not discuss her feelings during this meeting. During the week leading up to the review she didn’t mention the issue at all and avoided any invitation for further discussion. At the review itself we talked about it again and she listened and did not comment. It seemed that she was completely denying the possibility of leaving our home. Some days later we went climbing at an indoor climbing centre which is something we regularly do together. At one point she turned to me and asked: ‘when I leave your house, will we still be able to go climbing together?’ I said I hoped that would be possible. She had taken in the possibility of leaving and was starting to imagine what our future relationship might be like.
Apart from the occasional and almost dismissive passing reference Chloe has said nothing about the prospect of moving out. She probably cannot imagine what it means.
This week she is due to spend two nights in an independent living skills training flat together with a friend. Over the weekend she said nothing about this and avoided conversation about it. Monday morning she came down to breakfast in tears, saying she had never done anything like this before and that she was scared. We reassured her that we would be on call during her stay in the flat (which is 10 minutes walk away) and we contacted relevant staff to let them know how she was feeling. We also said that if she wasn’t ready for this it could always be postponed. She left the house in a happier mood. Without dismissing her distress, we noticed how she had managed to draw a lot of attention to her situation . She got the extra support she needed at college and came home happy and excited about the prospect of two nights away.
My partner Corrie helped her with packing, at her request. Corrie made it clear that she would not need more than could be carried in a small bag for her two nights away. Later that evening she asked me whether she could already bring her bag down. I was puzzled about why she would want to do that, however it became clear that she wanted to show me how big and heavy her bag was, insinuating that I should give her a lift in the morning. Chloe is adept at playing us off against each other but this time I managed to avoid being taken in by her charming attempt at recruiting me into undermining the work Corrie had done with her. Her big bag had wheels and she was able to walk with it to the flat in the morning. Upon reflection it did occur to me that the big bag was telling me that this was a big deal for her, that moving out is complicated and there is a lot to carry and this needs to be noticed.
Chloe was sharing the flat with another student and they need to pass by our house to go to the shops. Both evenings of her stay she managed to catch our attention as she passed the house, making sure she was seen and heard and therefore still present in our thoughts and not forgotten.
Chloe returned to our house enthusiastic about her experience. She said she had felt independent and free and had liked that. She was keen to repeat the experience and make it a longer stay.
After her two nights away, Chloe went to stay with her grandparents for the weekend. On the Monday after this she realized she had lost her wallet with her bank card and her bus pass in it. She was quite distressed about the loss. Her grandparents searched their house and we helped her look for it in her room. Only later that evening was she able to face the reality of having to cancel her bank card. She needed me to sit by her while she made the call, but managed the process by herself.
A week later, well into the half term break, Chloe sent a message to let us know she had found her wallet. It was in a side pocket of the big bag she had taken to the independent living flat. This was not the bag she took away for the weekend with her grandparents, so she must have put the wallet in it after she had come back.
I think Chloe genuinely lost her wallet and I think she also needed to lose her wallet to let us know about her anxieties around separation and independence. Chloe has regularly ‘lost’ a crystal she keeps in her pocket and which represents her mother. Invariably we find the crystal together somewhere in her room, often in her bed. The wallet with the bank card and the bus pass can be considered to represent Chloe’s independence. She ‘lost’ this in the bag which she used to temporarily move out of our house as a first step towards greater independence. The episode allowed her to rehearse emotionally and practically the consequences of losing her wallet with our immediate support. Letting us know that she found her wallet during the half term break also ensures that we do not lose sight of her during her absence.
Chloe told us she had had a conversation in her tutorial in college with our residential manager to discuss possibilities for her placement in her third year.
They had spoken about the possibility of Chloe living with background support and what this might mean. Chloe was obviously excited but also aware that it would be sad to leave our house.
This conversation confirmed that Chloe is really thinking about moving on, sees it as an important and exciting step, but can also think about the sadness of separation. She is able to hold and live with the ambivalence, which is a major achievement.
Interestingly, the conversation led to her looking back on her past experiences and acknowledging how much she had changed. For instance, she said it was now four years since she had last been restrained (at her previous school) and sent home for bad behaviour. What cannot be thought about is acted out. The acting out then needs to be contained. Restraint and suspension, whether or not appropriate, are attempts at containment. Chloe has obviously greatly developed her own capacity for thoughtfulness, managing her own containment.
In my essay ‘Residential Care as Therapy’ I wrote:
Graduated failure of adaptation plays an important part in Winnicott’s concept of the ‘good enough’ mother. The infant can start to meet the deficiencies with mental activity and thereby ‘turns a good enough environment into a perfect environment’ (Winnicott, 1949, p245). Our adaptations to the student in SLP settings may at first need to be near absolute, but should soon become relative, requiring the student to make use of an inevitable element of unreliability for their own development.
In his paper ‘From Dependence towards Independence in the Development of the Individual’, Winnicott (1963b) maps out three stages of this journey: from absolute dependence to relative dependence and then towards independence.
Absolute dependence requires a near absolute adaptation on the part of the caregiver. For a healthy self to emerge it is necessary that the moment of need is not always met. In Chloe’s case, when her desire to merge and identify with us is frustrated, she does not find her self in us and she meets us as separate people. This can contribute to her own objective sense of self. In the stage of relative dependence ‘an alternation of self and nonself experiences is required, the whole process occurring in an empathic, basically supporting, and reasonably consistent facilitating environment’ (Grolnick, 1990, p62).
The third stage, towards independence, is a fluid and ongoing process towards increasing independence without losing the healthy capacity for dependence on others (Grolnick 1990, p65).
Leo has left our household and a new student will come to live with us after the next half term holiday. When we first spoke about a new student joining the house this was experienced by Chloe as a disruption in her sense of consistency. She was upset and angry because ‘everything is always changing’. It was a mark of her development that she was able to process this in about half an hour and even articulate her anxiety that with another student in the house she may not get as much attention as she likes. We were then also able to reflect on the fact that she would be leaving our house soon, acknowledging the sense of loss and the sadness that comes with change.
As we welcome a new student to our house, Chloe will witness our adaptation to his needs, helping him to settle in and feel safe and secure with us and this at a time when she will experience an ongoing and conscious withdrawal from us as we encourage her towards independence. She is likely to feel jealous, but witnessing the journey of another student may also help her to internalize her experience of living with us as part of her own story. If she can take in the experience in this way she will be able to feel the loss . The loss becomes bearable and thinkable and even enriching. We are working towards separation without the trauma of abandonment.
(This student’s placement was postponed until after the summer holiday, which is why there is no further mention of him.)
We discussed Chloe’s needs for her next placement in supervision. In terms of Winnicott’s three stages mentioned above we concluded that she was very much at the stage of relative dependence where she still needs the alternation of self and nonself experiences to consolidate her own objective sense of self (Grolnick, 1990). We are starting to think that she is not ready for a provision with only background support. She could be helped to achieve the required independent living skills for this, but this would not meet her deeper developmental needs. The therapeutic approach would be to provide her with further experiences which will consolidate her emerging objective sense of self. Support needs to be in the background, but very reliably available when she needs it.
We had an ex-student to visit for the weekend. Chloe had met this student on a previous visit and was looking forward to seeing her again. Chloe started to imagine and talk about how it would be when she comes to visit in the future and she listened to us sharing memories of a time before she had joined our household. There was a lot going on for Chloe. The visit highlighted the transitory nature of a student placement in our home. She coped quite well with the attention our visitor was getting, reassured that she could expect the same interest in her stories when visiting us in the future. We had planned to all go out for a walk on the Sunday, but at the last minute Chloe decided she did not want to come. She was able to say discretely that she was finding being with our visitor difficult and she needed time on her own. During our walk I thought to myself that by opting out she was accepting and possibly grieving the need for her to separate from us. When I asked about this later she simply said she had been watching a film.
After the half term holiday we had a long chat about many things. Towards the end of this Chloe expressed her concern about not knowing where she would be going after the summer. She said not knowing was difficult for her. From introducing the possibility six months ago, she was now accepting the move, even feeling excited about the possibilities it might offer but also able to articulate what was worrying her about the process.
Chloe is initiating conversations in which she shares memories of the two years she has been with us, demonstrating that she is engaged in the process of moving on. Looking to the future she sometimes says she is fed up with college and wants to move on and have a place of her own. In the face of not knowing where she will go next, she starts to imagine her life after college. We have alerted residential managers to the effect uncertainty is having on her, but decisions keep being put back week by week. Chloe trusts that we are doing the best we can and this makes the situation tolerable for her. I have told her that I am not able to guarantee that it will all be sorted before the summer holiday but I have assured her that I will do everything I can to make it so.
Not being in control of the situation Chloe has become more controlling in other, rather trivial situations. One example: we bought a slightly different variety of muesli which she complained about, saying some of the berries in it were too sharp. The fussiness may be understandable in terms of taking control of something in her life and expressing the need for us to get breakfast ‘just right’ for her.
Chloe has also found situations in which she expresses helplessness. She has had the opportunity to cook independently for herself two evenings a week but has gradually withdrawn from this, demonstrating uncharacteristic incompetence, for instance being unable to cook some pasta, something she has done for herself before. Interestingly, this is again around the provision of food: Chloe is telling us she does need to be looked after and fed properly. One morning she dropped a glass of juice on the floor. She looked at me with alarm and exclaimed: “I don’t know how to clean this up!”
In terms of her placement for next year, it is becoming increasingly clear that Chloe will need more than background support. She often says she wants to be left alone. She enjoys doing things by herself and the sense of independence this gives her. However, she is also clearly demonstrating that she needs reliable and consistent care and support available.
Chloe’s relationship with Rob, the other student in the house, seems to be deteriorating. She is finding him increasingly annoying, can be unpleasantly bossy towards him, interrupts him and gives him the occasional poke in passing. September, when Rob joined us, she was quite honest about feeling jealous of him being the new student who gets all the attention and she found it hard to adjust to being the second year student. It is probable that Chloe is feeling jealous of the fact that Rob will be staying with us and that she is the one who has to move out.
On the whole Chloe is being very mature and accepting of the move. I would say she may be too mature and accepting of it and I guess she is not able to fully express her anger and sadness about leaving yet. We need to provide possibilities for these feelings to be acknowledged and expressed. We can do this by offering our thoughts about the various relatively trivial incidents as described above that occur from day to day, putting them in the context of the changes ahead and the uncertainty about these changes.
I told Chloe that we would not know about her placement for next year until the end of next week. I explained that this was because it was becoming apparent that she was not ready for the placement with background support that had been discussed previously and that other placements were being considered. This seemed to be a relief for Chloe even though she continues to be anxious about not knowing where she is going or who she will be with. We spoke also about the sadness of leaving. She said she tries not to think about this because when she does she cries. I acknowledged the sadness of parting. It was a heartfelt exchange in which Chloe both expressed and contained her own sadness.
Chloe has spent the weekend from Friday morning to Monday evening in the independent living flat. This time she wanted to be on her own rather than sharing with a friend, to see what it would be like. She came back to the house on Friday evening to get her bike, she phoned us on Saturday evening for some advice on cooking, popped in for a chat on Sunday morning and brought her bike back on Sunday evening. Once again she was making sure that we were holding her in mind. However she was much more confident and self contained this time. On the Sunday evening she was in tears, this time not because she missed us but because she didn’t want to come back and wished she could stay in the flat. She said she longed to have her own place to live. She was expressing her desire to separate from us and experiencing the sadness of the separation and found herself able to contain the ambivalence of these feelings. There was great hope in her capacity to imagine a future for herself where she would be responsible for her own life. When she came home on Monday afternoon she acknowledged that although she liked being on he own, she would need people around her for advice and to suggest ways of doing things.
Finally the college was able to confirm Chloe’s placement for next year. It was the placement we had been hoping for. Confirmation of the placement brought home the reality of leaving and Chloe was upset in what felt like a very genuine way. After the tears she was able to express how much she would miss us and how much she felt she had learnt from being with us.
In the last week Chloe said in passing to my partner: “I’ll miss the cuddles, but not the fights”. A few days later she said: “I’ll miss the fights as well”. It felt like there was a real sting in this remark. However, thinking about what this could mean, we realized that in the cuddles Chloe loses herself in the other, in the ‘fights’ she loses the other and finds herself. In discussing this with her she understood and confirmed this. She said: “Thank you for making me who I am”. We would not claim to have done that, but we do know we have helped her on her way.
We have ‘survived’ another year of sharing our lives with students. Both Leo and Chloe have in their different ways been a thorough nuisance to us and Winnicott taught us to consider this a sign of hope. We loved them and we hated them and they both pushed us close to our breaking point. With Winnicott’s theoretical framework in mind we were able to acknowledge the feelings this provoked but also remain thoughtful about our task.
We involved these students in a planned process of separation and thereby maintained our reliability during this transition. Winnicott’s insights allowed us to engage with a wide range of feelings provoked by this process without becoming sentimental or vindictive in our interactions with the students. We were able to support the students in the containment and the expression of their feelings and thereby with the integration of their experiences.
Leo came to visit us on a few occasions during the summer term and expressed his appreciation of his time with us. To me this endorses Winnicott’s view that the therapeutic value of residential care may lie not so much in treatment or cure but in survival, more a matter of ‘being with’ than of ‘doing to’. I do have a sense that Leo has been able to make use of me, although I cannot provide measurable outcomes.
Chloe has managed a process of separation without suffering the trauma of abandonment. In grieving, reminiscing, celebrating and anticipating she achieved a remarkable degree of integration. Over the two years she was with us we found her to be very intrusive, an expression of deep anxiety around abandonment. Winnicott helped us to keep in mind that the intrusiveness was a symptom. Boundaries needed to be established and there was a lot of emotional holding to do but moral judgements were of no therapeutic value. Chloe left us with a greater capacity for self containment and may well have become a bit more like the person she might have been ‘if (her) untoward environmental breakdown had not brought disaster’ (Winnicott, 1970, p196).
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