As more complex and troubled children and young people are routinely placed in care there has been much thinking about the types of model of caring that may work best for a routinely traumatised population. This has led to an increasing interest in what is often termed ‘therapeutic care’. This can lead to the term ‘therapeutic care’ being used in lots of different ways and about widely different provision. Does the offer of counselling to a child once a week or consultation for carers or staff once a month make a provision therapeutic? It may indeed be very helpful and address some of the carer’s and child’s needs. However, I think that therapeutic caring goes beyond this. It is a way of understanding both traumatised children’s difficulties and the sorts of caring relationships which can help children heal. As a basis for a therapeutic foster care training a model of therapeutic caring has been articulated which could be seen as being equally relevant in adoption, extended family care, residential provision, education, forensic and mental health settings. It is based on what is called a bio-psycho-social model which incorporates neurodevelopment, psychotherapeutic, psychological, social and relational models, theories and practice. This two page table is in reality part of a work book of over 200 pages and a course that lasts 15 days with the central tenants of developing reflective practice, providing a theoretical grounding and allowing lots of opportunities to develop relational practice skills. So this distilled knowledge requires a lot of education and input to assist people to get to a beginning place in using such a model. But it hopefully provides a kind of guidance, a frame to work within, a setting out of one’s stall when one uses the term ‘therapeutic care’.
|Orb8 Model of Therapeutic Caring
A Bio-Psycho-Social Model
Copyright Dr Jane Herd Orb8
|1. Put behaviour into context including social, community and contextual history. What has passed from in utero to the very first months and year/s of life will have a lasting impact on brain structure, functioning and related bodily processes. This will lay down relational, social, linguistic, bodily, sensory and cognitive patterns which will be the basis for how the world is experienced and responded to, this is their internal working model. Knowing what has happened in the past may help to make sense of the present.
|2. Learning your child, your child will have a different internal working model of the world based on their experience of it. One of the jobs of a therapeutic carer is to work out as best they can what their child’s internal working model of the world is, which may be very different from theirs and other children their age. Ways of working this out can include close observation, and seeing behaviour as communication.
|3. Windows of tolerance- based on a child’s inner working model they may be substantially more or less tolerant of external and internal stimuli. Resultant externalisation or internalisation can be perplexing, confusing, and distressing for the child and carers. Carer’s need to work out what their child can tolerate, understand and use and what triggers them into disregulation.
|4. Behaviour as communication; behaviour is not usefully viewed as good or bad but needs to be viewed as a communication letting others know what a child can or can’t manage or understand, what distresses and destabilises them and what this may say about their internal working model.
|5. Mind-mindedness and mentalisation is an extension of empathy, it is being able to get a sense of others emotional, social and intellectual ways of being. Traumatised children often have poor mentalisation capacities, this can be patchy and they can lose this capacity when anxious or distressed. Even if the emotional state is not obvious the lack of mentalisation function can be very obvious as they won’t understand how they or anyone else feels or what they need.
|6. A carers needs to relate to a child with curiosity, wondering, empathy and humour. Aiming for expectation failure, to move away from well worn patterns of behaving and relating to something new, allowing for new brain pathways to be created.
|7. Shame, rupture and repair- young children need to feel sorry for doing things that upset others, this is when they are gently told of, the relationship has been ruptured by the admonishment and repaired by making up again. When there is no repair or the response to unwanted behaviour is harsh the child will not feel guilty- that they have done a bad thing but they feel shame and that they are a bad person. This can lead to terror of abandonment. Children who feel a lot of shame can find it impossible to take responsibility for anything (even if you see them do it!) and can be very controlling and need to feel in charge.
|8. Co-regulation, a traumatised child is very unlikely to be able to regulate their emotional and bodily states and functions as a starting point. Carers need to set the emotional tone. They need to join the child where they are with shared attention, intention, mirroring affect, tone and rhythm, start where they are and take them closer to where you want them to be. Follow, lead, follow.
|9. Up and down regulation; safe risk taking and physical exertion to burn off excess adrenalin and cortisol and begin to safely regulate may avoid acting out behaviours as can calming quiet times and usually a mixture of both is required.
|10. Boundaries are very important and useful for traumatised children. This means you need to set the environmental, emotional and relational tone and space. Regularity and rhythm is important, minimising over-stimulisation and disregulation, think vanilla!
|11. Avoid punishment and behavioural strategies such as rewards which encourage manipulation and ‘playing the game’ as part of survival mode and exclusion such as the naughty step which increases shame and isolation. These are likely to fit into existing unhelpful patterns of managing the world and will reinforce them, not lead to change.
|12. Natural and relational consequences are much better learning tools than punishment, the latter may make carers feel briefly better at times of stress but they are unlikely to lead to real change and may increase shame and related negative beliefs. Parents often come reporting using behaviour management strategies with ever increasing sanctions and complain they don’t work, they are quite right, they don’t! Natural consequences such as not replacing something broken for a period, or spending time repairing it link behaviour with consequences and feel fairer and are more likely to make sense to the child. If child has hurt someone’s feelings emotional and relational consequences such as giving someone a back rub, making them a cup of tea, or writing them a kind note are all congruent and can help build empathy.
|13. Traumatised children and young people get inside of us. In fact this is a regular part of relating and a part of mentalising. However, traumatised children can get in us in such a way we end up not knowing what are their feelings or ours. We can end up fitting their previous patterns of relating which they may be used to but will feel pretty stuck and uncomfortable for others. Regular supervision and reflective spaces can help carers reflect on what might be going on for them and the child below the surface, things that you are both acting out without being consciously aware of, naming and recognising them can help things move on.
|14. Carers self-regulation requires attention. As well as learning the child carers have to learn themselves. What triggers them, how do they feel when regulated or disregulated and what helps them calm and get back to a regulated state. What goes on inside them, sensations, feelings, metaphors, thoughts, behaviours and how do they link together, can they help carers make sense of their and the child’s world.
|15. Self-care is really important. Parenting is hard, therapeutic parenting is really hard. There will be an emotional impact, it is important to map what this is and have strategies for self-care .
|16. Ambiguous loss is loss that is not clear, people are gone but not knowingly dead they may come back at a moment or be gone forever but psychically ever present. This makes change, relationships and loss very difficult to manage and a child’s experience of loss needs to be mapped out and made sense of for the carer and child.
|17. A child’s social context remains of great importance throughout their childhood. They will often feel more comfortable in situations or relationships which fit with early patterns and their internal working model. This can be particularly problematic in adolescence when they naturally look to peer relationships rather than parental guidance for their steer as to how to behave. Contextual and environmental risks need to be considered and worked with openly.
|18. This is never, ever quick work. You may get some quick wins and sudden breakthroughs but mostly it is plodding away day after day. It is worth reviewing where things are at on a regular basis as subtle and slow progress can often be missed. Carer’s may feel you have to do things a 1000 times and sometimes you really will have to, it takes 10,000 hours to get really good at anything, including managing your feelings and relationships.
The Orb8 Model of Therapeutic Caring was created by Dr Jane Herd founder and Director of Orb8 a small UK organisation with a particular expertise and interest in working with providers of care and services to hard to reach, traumatised and hard to reach children, young people and young adults.