I want to explore this subject by thinking through the experiences young people have when they actually leave the care system. I will do this by telling the story of one young person I have recently met preparing to leave care. I will refer to both the internal experiences of care leavers and their external experiences.
The process of leaving care is clearly unique for each individual young person, however. Many leave the care system close to their eighteenth birthdays. In my work role of Child and Adolescent Psychotherapist I meet quite a few late adolescents who are or have been in care for most of their childhoods.
Luke, now 17, was removed from his mother’s care when he was about five along with his brother as a consequence of his mother’s addiction to drugs and alcohol. He was initially placed in his father’s care as his parents had separated when he was very young. He then spent about three years in his father’s care and his memories of this time are of generally good times apart from when his father would drink excessively and become very aggressive. This culminated in a frightening incident in which his father drunkenly killed his dog with a knife in front of him. It was after this incident that Luke was taken into care and initially placed with a foster family.
Luke recalls never really fitting in with the family, with whom he lived for about two years, and has slightly vague and sketchy memories of moving between foster families and his father’s care until he was finally placed about forty miles from home in a children’s home where he lived for two years from the ages of thirteen to fifteen. He was then moved from that home to the one he now lives in, based in his home town in the north of England.
My first involvement in Luke’s life was an invite to a network meeting in a social services building situated on an industrial estate in the town in which I work in a hospital-based Child and Adolescent Mental Health Services clinic. I struggled to find the place and hence arrived about fifteen minutes late for the meeting. I had been asked by a psychologist colleague to attend the meeting with a view to thinking about how I might be able to help in the longer term. I finally arrived, slightly flustered to discover the children’s home manager and social services team manager in quite a hostile and angry mood. I thought my lateness might have exacerbated this and was very apologetic. However, the mood of hostility and anger continued as my two colleagues proceeded to complain bitterly about the prolonged inactivity of CAMHS in relation to Luke. I felt attacked and barely able to think straight and took note of my psychology colleague’s attempts to placate their fury.
In time I began to think about the undercurrent of blame and dissatisfaction and recalled how Luke was a boy whose parents had really never been able to ‘come together’ with his best interests at heart and began to think we were very much playing out something that must be very familiar in his life. When I shared this slightly abstract idea, the response was almost disbelief on my colleagues’ faces but it led to a slight thawing in hostility. We eventually agreed that my colleague and I would talk more and agree a way forward in terms of how CAMHS might try to meet Luke and his network’s needs.
In this first discussion it emerged that Luke was generating very high levels of anxiety in those who know and care for him. His repertoire of worry-inducing behaviours included anal masturbation using chair legs, dressing up in female clothing both in his bedroom and on occasions outside of the children’s home. He was also buying PVC clothing from sex shops and experimenting with dressing up in these and inserting a ‘plug’ into his anus. He was also defecating on his bedroom floor on a daily basis.
I also noted in these early stages an overwhelming need in the network to somehow locate the right ‘expert’ who would alleviate all these worries. The case had been referred to specialists in Liverpool and people were now wondering if it needed to be exported to a centre of expertise in London. Was this an emerging gender identity development case or something more multi-dimensional and complex? I began to feel under pressure and slightly set up to become the ‘new expert.’
Communication and Complexity
Reflecting on this meeting with my colleague, I soon realised that we both viewed the case through very different, potentially complementary, lenses. My colleague, at least by my perception, was more inclined to take communication at face value whereas my own tendency was to hold onto underlying and deeper possibilities, including what the emotional experience or transference might tell us about the case. It was this that led me to have the thought about where the strong feeling of blame we encountered might have originated.
We agreed a plan of action that would involve me taking on a lead role in the case whilst continuing to collaborate on work with the network. We agreed it would be important to remain joined up, as there was felt to be a tendency to attack a more reflective approach to the work and a general and understandable reluctance or inability in the network to really stick with the harsh realities and difficult feelings aroused by the case. It was agreed that prior to any psychotherapeutic assessment being undertaken it would be useful to allay some of the anxiety about risk by requesting an urgent assessment from a local multi-disciplinary forensic service familiar with this type of work.
I do not want to over-elaborate on the theme of communication here but, perhaps inevitably, the main characteristic of the communication on this across agencies was that of incoherence and splitting. The difficulties in managing this were exacerbated by the continued strength of negative feeling felt by the social care members of the network towards the health members, myself included. However proactive and inclusive I attempted to be, for example copying every e-mail on the subject to every member of the network, something in the following few days would occur that undermined any real sense of togetherness and cohesion.
I also became aware that the more involved I became in the life if this young man the more consumed I felt by the experience and the more hopeless and helpless I began to feel. Clearly this must be a large part of his – and arguably most care leavers’ – experiences.
Assessment with an Eye on the Past, Present and Future
As we all waited to hear the outcome of the forensic assessment I felt my task was to hold the network in mind by talking to them regularly on the telephone and being flexible and responsive in their ‘hour of need.’ I responded to one particularly panicky phone call from the social worker by agreeing to attend the children’s home the following day to help the staff think about how they might manage an escalation in Luke’s defecating on his bedroom floor. The most memorable aspect of this experience was an almost total absence of any hostility in the air when I was in the actual home, although I later received some very negative feedback from the manager in a questionnaire that I’d left with him which wasn’t particularly a surprise but seemed a bit cut off somehow from what appeared on the surface at least at the time.
I needed to chase the forensic assessment report as the deadline day came and went and eventually received a very long, thorough report that I later discovered had been written on the basis of a one-off consultation with parts of the network but no actual face to face contact with Luke himself. The report made harrowing reading and ended with a recommendation that Luke be placed in ‘a specialist therapeutic residential placement.’
It rang alarm bells understandably about the high levels of risk he is likely to present to himself and others if he is not to be provided with specialist input. It was also recommended that he be seen urgently by a child and adolescent psychiatrist before undertaking a psychotherapeutic assessment with myself. This would serve the purpose of ruling in or out symptoms of psychosis and depressive illness and decide whether or not he should be prescribed medication.
After meeting with the network, again in a slightly frosty and hostile atmosphere to feedback the content of the forensic assessment and the psychiatric view that he was not psychotic or severely depressed, it was agreed that I would begin a psychotherapeutic assessment with Luke and we agreed a date upon which we would all reconvene on which decisions could be made about how best to meet his future needs.
Half way through my assessment I received a number of slightly confusing messages from the NHS complex case manager saying she needed every report that had ever been written about Luke on her desk within seven days as she needed to make a decision about whether or not health would pay for part of the specialist placement he needed. I replied with a polite e-mail pointing out that I was naively hoping my own ongoing assessment might have some influence over this process and its outcome and she eventually agreed to attend the final network and planning meeting prior to making final decisions.
I do not want to settle into the fine nuances of my assessment work with Luke here but do want to register that he is an unusual young man with a very plausible, likeable exterior and a lack of emotionality that leaves one filled with a strong sense of uncertainty as to what’s really happening on the inside. His memories and stories of his past are told with a strong sense of both uncertainty and matter of fact-ness.
In relation to his future he was very certain that he would not want to go to any specialist type of setting but would rather stay where he is now in his children’s home or return to his mother’s home where she now lives with a man whom she is about to marry later in the year. In his mind she is off the drugs and in better shape than she has been for most of his life. If he was able he would like to join the army as soon as possible and become an infantryman and work towards becoming a sniper one day! This is, however, not likely to happen until he is eighteen and his Care Order comes to an end at which time he can do what he likes!
My sense of Luke was of a profoundly lonely, lost and confused boy emerging into manhood without solid foundations to his personality. Adolescence had clearly reawakened infantile, sexual longings that had yet to find any true meaning or legitimacy in terms of connectedness with others. Indeed in some ways he seemed perversely self-connected as well as profoundly disconnected both internally and in relation to others. Ordinary adolescent process and development is rarely easy or straightforward but is assisted through opportunities for identification with peers and often parents or parental figures. I felt uneasy and uncertain about Luke’s identification with the army and all this entailed.
My greatest area of unease lay in the question of what was fantasy and what was reality? The assessment took place at the same time as Derrick Bird killed twelve people and wounded many others before taking his own life and I had numerous fantasies of my own in which Luke carried out similar actions and was later able to talk about them both dispassionately and disconnectedly. I was also unable, in the way he was, to connect or link up how to reconcile cross-dressing, encopresis, and anal masturbation with life in the barracks or on the frontline in Afghanistan.
The multiple families in the minds of most looked after children present a very particular challenge to their experience of the adolescent developmental process. With whom can or should they identify and what does becoming mother or father-like mean in developmental terms when you have had so many? In my experience the primary psychic attachment and bond to birth parents and relatives rarely fades in looked after children whether they are alive or dead, absent or present and many actively seek them out for some kind of reality testing as they develop into young adults.
Clearly the external reality for many looked after children as they leave care is also quite bleak. I think the quality of disharmony and distrust that surrounded the multi-agency discussions focussed on Luke’s future are not at all unusual. The despair, hopelessness and tendency towards blame are all too frequently experienced when one encounters young people approaching adulthood who still have many of the characteristics of toddlers and primary-aged children. It almost seems to be doing them an injustice to be talking about independent living skills and budgeting skills when most parties present are all too well aware that they are functioning as a much younger child and would benefit from a continued level of very high but unprovidable support.
Ideally transitions out of care might be experienced more and thought of more as transitions into new forms of care. In many instances birth parents are likely to be key players and potential collaborative partners in this process. If not, then perhaps the continuing role and responsibilities of the corporate parent(s) needs to be radically rethought alongside the conscious and explicit need these young people have for enduring attachment figures in their lives.
When I broached this subject with Luke’s children home staff it was clear that once they turn eighteen these young people leave and in most cases never return, nor are they pursued in any way.
In many ways ‘after-care’ is a forever state for children and young people corporately parented. For Luke his life ‘after care’ is yet unknown but it is hard to feel particularly optimistic. I have heard colleagues talk about young people who simply ‘grew out of’ worrying states and behaviours, and time will tell. I recently heard a damning statistic that 45% of this country’s young offender institutions are inhabited by young people who have spent time in care. This tells us something, I believe, about both the power of parenting and the power of what happens when parenting goes wrong for whatever reason.