No Man’s Land: Making a Map The contribution of child psychotherapy to decision-making for Looked After Children in transition Marie Agnes Bradley MSc; CQSW; MPsych Psych; MPsych Adult A thesis submitted in partial fulfilment of the requirements of the University of East London for the degree of Professional Doctorate in Child Psychoanalytic Psychotherapy The work was conducted in conjunction with the Tavistock Clinic, London and Parkside Clinic, London. October 2013 Table of Contents Abstract Acknowledgements Dedication Chapter 1: Introduction 4 1.1 The Research question 1.2 No Man’s Land Chapter 2: Literature Review 11 Chapter 3: Research Methodology Part 1 47 Contextualising the study Chapter 4: Research Methodology Part 2 75 4.1 The sample 4.2 Data collection and analysis Chapter 5: The case study of Danny 91 Chapter 6: Similarities and Differences 185 Chapter 7: Conclusions from the research 195 APPENDICES Appendix A: Assessment report for Danny 206 Appendix B: The stories and assessment material from Sophie, Millie and Oliver 213 Appendix C: (i) Ethics Committee Submission 265 (ii) Letter of Acceptance (iii) UREC letter of confirmation 290 Appendix D: Letter to Social work team leaders 290 Appendix E: Research Information sheet 292 Appendix F: Consent forms 293 Appendix G: Strengths and Difficulties Questionnaire for teachers 297 Appendix H: Semi-structured interview schedules for social workers and foster carers 299 REFERENCES 306 Abstract The research is a small-scale study of the potential benefits of Child Psychotherapy assessment of Looked After Children in transition, for the child and for the professional network caring for the child where the child psychotherapist-researcher is part of the network working together to plan for the child’s long-term future. The assessments aim to bring specific understanding of the child’s emotional state and emotional needs, of his perception of what has happened in his life and of the ways in which his development has been influenced by these external events and perceptions. The assessments also explore the potential for the work to help the child make sense of his history and of himself and the assessments aim to be a distinct and essential part of the overarching assessment process which informs preparation of the children and their prospective carers for permanent alternative placement. Four latency-aged children in transition were assessed in an inner-city community- based Child and Adolescent Mental Health Service by the clinician-researcher. using Standard child psychotherapy techniques were used with some adaptations of technique to address the children’s transitional status. The assessment framework included in-depth interviews with social workers and foster carers and information from schools. Process recordings of the assessment sessions are the primary data in this enquiry and these are analysed using an adapted version of Grounded Theory methodology. The depth and complexity of the children’s experiences and their internal worlds is strikingly revealed by the assessments, in new and compelling detail. All of the assessments were highly significant in shaping short and long-term provision for the children. The outcome of the study strongly supports the inclusion of child psychotherapy assessment as part of an integrated, multi-disciplinary assessment process for all children in transition. The method of assessment and of analysis of data transfers well to a range of Looked After Children in transition in the study as well as providing an effective basis from which to communicate clearly and effectively across interdisciplinary boundaries: making possible a more truly representative, responsive and integrated map for the future. Word count 68396 1 Acknowledgements I thank my supervisors Dr. Dora Lush, Professor Michael Rustin and Mrs. Jenny Kenrick for their wisdom and constant support. I thank Dr. Grace Jennings for her rigorous and thoughtful encouragement and friendship and I would like to thank Gabrielle Crockatt Consultant Child Psychotherapist and my colleagues at Parkside Clinic, the children, their foster carers and their social workers for helping me to grow. 2 Dedication For my daughter and all my grandchildren and their parents 3 Introduction The research question: In what ways can Child Psychotherapy assessment contribute to understanding the long-term needs of Looked After Children when planning for their permanent placement? How can this contribute to the work of the professional network around the children and how do the children themselves respond to this intervention? No Man’s Land: Examining the lived experience and the state of mind of children in temporary foster placements, Janet Philps’ (2009) observes and describes ‘borderline’ (Rey 1994) features in their ways of perceiving and responding to the extreme uncertainty and conflict inherent in their transitional care. Rey describes the essential feature of borderline states of mind as the difficulty or even absence of communication between different parts of the mind which represent emotional experience and which together make meaningful sense of our lives and of who we are. In borderline states of mind these parts ‘go on functioning separately and are incapable of integrating’ (ibid p3.) In the context of transitional care, Philps observed that the children and to some considerable extent their carers and social workers turned, largely unconsciously, towards this borderline way of functioning. Keeping experiences apart which, if connected, might overwhelm the individual with anxiety and despair, offers a formidable defence against emotional integration; it is a profound response to the terror of such extreme uncertainty. There is an understandable longing for life to continue in the most ordinary way possible, as if it was ordinary. There is a hope that children will resume growing and developing when they are relieved of the immediate impact of the unsustainable family situations from which they come. To this end something of an agreement may be reached, to live ‘as if’ (Deutsch 1965) the life the children are living is a reliable and integrated experience. The capacity to make use of the relative steadiness and containment of temporary care is necessary and helpful but the splitting often sought between external and internal experience, to survive the 4 inherent emotional trauma may mean that real development is often suspended beneath a semblance of ‘moving on’. Making a map: The way forward is sought through the concerted efforts of the professional network around the children. A deeper and more complex understanding of what constitutes a child’s potential and the factors which tend to enable and limit it has grown over the past seventy years. There have been significant developments in our understanding of human development and human needs, from theory, from developments in practice and from developments in social policy which have supported changes in addressing human needs (Johnson and de Souza 2012). Networks: Each part of the network around the child will explore his needs from a particular professional perspective. Each part of the network is working towards finding the right home and the right parent(s), where the child can grow up, continue his development and realize his potential in every sense - physically, socially, intellectually and emotionally - to the fullest extent (HMSO 2003). Longstanding difficulties continue to be observed in communication and integration between component parts of the professional networks around children and between these and the networks around their parents (Rustin 2005; Laming 2009); working together effectively to reduce these difficulties continues to be a struggle (DoE April 2012; DoE December 2012); highly significant factors contribute to this struggle, including the under-resourcing of social work services leading to high ‘burn-out’ and turnover rates in staffing and the lack of satisfactory support and supervision of this highly demanding work. There are other less easily observed factors which militate powerfully against integration in the professional network. Organisational defences (Emanuel 2006) against the emotional pain of working with traumatized and highly distressed children and families elicit powerful and often largely unconscious defences against the emotional experience of being in touch with such experiences, of which splitting and denial are central (Cooper and Webb 1999; Menzies Lyth 1988) and which potentially damage and limit the work which is possible. 5 Psychoanalytically-trained child psychotherapists are equipped to explore and address the powerful unconscious determinants of human behaviour and the thoughts and feelings behind it. In the professional network the child psychotherapist is usually primarily a practitioner working individually with the child but she is also a core member of the team around the child in the assessment process. The decision-making process for Looked After Children in transition charges us as human beings and professionals with the emotional impact of facing and understanding the most painful of experiences; it is difficult work to remain genuinely in touch with these, open to what is communicated while maintaining the capacity to function in such work without resorting to defences which protect from the experiences and separate workers from the children and from each other. Child psychotherapists learn from theory, practice and experience to bear ‘unbearable experience’ (Reisenberg-Malcolm 1999) in a realistic way; this is what the child psychotherapist can bring to the professional network of which she is a part (Emanuel 2006). ‘Making a map’ signifies the process of bringing together past and present knowledge and understanding of a child in transition from multiple perspectives so that his future can be approached realistically with some hope, some confidence and more understanding of what it will take to make a good future possible. This thesis explores how child psychotherapy can work together as part of the multi-disciplinary team which puts together a meaningful account of the child and his needs. The contribution of Child Psychotherapy to decision-making for Looked After Children in transition: Children growing up in adversity often find it difficult to put into words what they think and feel. Their experiences of growing up always include very significant experiences of trauma and loss. These experiences frequently impact powerfully on children’s capacity to use their minds to explore what happens to them and the development of a mind which feels confident and safe enough to engage with and enjoy the world beyond their immediate circumstances may be very much restricted. Living with the unpredictability and deep anxiety of direct or indirect abusive care by the adults on whom they depend takes a heavy toll on children and they will try to 6