When the going gets tough Sharon Pettle

I am going to ask you to change lenses, to change focus for the next 15 to 20 minutes from the level of programmes from the level of the families that have been abused and away perhaps for a moment from cultural issues into micro moments of us working with adolescents and their families. Many people who are at this conference have been drawn to work with young people because of how rewarding this can be. So there is an abundance of energy to harness, people are young enough to change perhaps more quickly than adults who have years of habits to overcome, they have more cognitive capacity to grapple with complex issues and a multitude of feelings of younger children and sometimes a real personal motivation to sort out their difficulties.

These are the easy ones. The ones we like to work with, the teenagers who help each of us feel good about the work that we do and whose occasional non-attendance brings on disappointment rather than relief. But what of the others? The ones who sit silently, barely making eye contact in a session accompanied by one or more parents or worse those who come alone to a session in which a therapists feels more akin to a dentist pulling teeth than a sensitive person who has created a safe and secure environment in which troubles and worries can be expressed. Silence can indeed be tough. I spent a number of years working in in-patient settings with disturbed adolescents and learnt something very simple but very important earlier on: working at the sharp end with the young people often with extensive professional network surrounding them can be daunting for everyone not least the young person. It was not uncommon for myself and colleagues to go to a consultation meeting where they would be 7 or 8 professionals, 1 or 2 parents and an adolescent.

Facing entry to a psychiatric unit for a teenager is pretty massive. Let us not kid ourselves, this is how teenagers see it. It only happens when things are pretty bad and people can’t cope with what you are doing. When meeting these families for the first time a colleague suggested that a formal handshake with everyone was appropriate. I am not sure how you greet your clients. I am not sure what I did before that comment or how formal I was but the comment certainly made me think about the important communications that take place in those first few seconds. How did I convey respect, what did I do that gave a message that I was interested in everyone’s view point and particularly in the eyes of the adolescents gave a message that I have not already ganged up against them like everyone else. In this culture there are few conventional ways to greet people. We don’t bow, too much physical contact is inappropriate and a hand shake at least fits common practice even if in this day and age it’s a little antiquated and conventional. As professional we may greet new colleagues in this way and I certainly saw earlier this morning colleagues meeting for the first time here and shaking hands so when I went on a consultation that was very often the way that I introduced myself and greeted new colleagues. So greeting colleagues in this way surely it carries the message to parents that they are no less important. And there by implication was the need to include the young person. Young people may respond limply, it’s true, but in my experience they rarely fail to extend a hand and my offering mine subtly conveys a message which does not place them apart. My colleague further suggested the importance of eye contact, sounds incredibly basic but it was very important which if the atmosphere feels appropriate I’ll sometimes say lightly, you can do better than that when a well-built teenager offered a soft limp sort of hand. A brief glance might follow, we might smile and at the very least something is gleaned by me in the exchange often in the waiting area about family relations, the young person’s state and the difficulties or not that there may be to engage them.

Imagine this scenario: into the consulting room walk 2 parents and a sullen looking teenager. The therapists makes initial contact with the parents who explain in detail what it is that their child is doing or not doing. The therapist aware the teenager is not contributing to the conversation invites him to join in, maybe to comment on his parents’ description. He remains silent and looks at the floor. Further attempts to include him meet with resounding failure and the session continues as an interview with disgruntled parents who feel that their son showed himself to be as difficult as they believe he is exemplified to his non-responsiveness to the occasionally proffered question. This may sound familiar. The therapists has a range of feelings, anxiety and impotence to name just the two, trying harder and harder to make the adolescents speak, doing more of the same simply compounds these feelings. Re-framing or positively connoting the silence can be useful in redefining the behaviour as helpful in some way. It may be worth trying some of the following: I have sometimes said, I’ve met many adolescents who wouldn’t let anyone to get a word in edgeways, I am impressed by your ability to give other people the space to talk, or you seem to be very good at listening, I suspect that you are doing a lot of thinking about what your are saying, I’ll be interested to hear your view when you feel ready to speak, or even I think you are wise to wait until you are sure that you can trust me in this context before speaking about the situation at home.

When the silence is accepted and valued as the young person’s contribution it makes it more possible to invite other family members to give opinions from different perspectives. Circular questioning - a technique from systemic therapy involves the silent member in a different way, for example I might say to a sibling, you sister was asked what are the things that make her so angry what do you think she would say. This may bring forth interesting and important information and the silent teenager may not or shake vehemently their head or angrily deny what has been offered. At the very least more information has come out. Alternatively I might ask if someone else in he family was going to speak for you. Who would be the person you would most want me to ask questions of? If they don’t want to use their voice try ask the adolescent to point to point to someone or use some of the non-verbal signals that you have noticed by asking, I see you look at your older sister a lot, would she be able to give me an idea of what you think. Prescribing the problem is another of acknowledging the silence. This sort of comment also conveys understanding that coming into a therapeutic counselling context is not always an easy step and trust has to be developed. I have often said I really think it is important that you don’t speak for a while, maybe until the next session even. It’s very important that you think carefully about what you say and make sure that you are ready to join the discussion.

Some of the strategies might succeed, when they do not it’s hard for a therapist to avoid the temptation to repeat attempts trying harder and harder to gain control. The risk of the unhelpful asymmetrical escalation grows. A strategy that did not work the first time is unlikely to succeed if used again. I feel pleased when I manage to try something different or not to be further organised by the silence. In my experience trust is more likely to be built up and silence less ominous if the scenario I mentioned just before can be avoided. If the holy problem orientated diatribe can be curtailed before it becomes overwhelming a connection with the young person is more likely. Engagement is a very important part of beginning sessions and often receives little attention in training. Those first few minutes can be crucial. Like many people I often try to ask about strength and what is going well in the life of teenagers and their families. Brief and solution-focused therapists and those interested in narrative approaches like have encouraged us all to explore the non-problem areas of the lives of the people that we meet. What do they like about each other, what was it like when things were better, what would they would like things to be like in the future - these may all be useful questions and may present new information that makes the difference to how people see themselves, see each other and to how they relate. At the very least they give us a wider picture of families’ lives and may give clues that may help in the pursuit of change.

Some therapist favour ending session in a way which conveys a message to the family and may suggest a therapeutic task for them to undertake before the next session. Validation g all the member of the family, addressing comments to each individually even somebody who has been silent throughout contributes to the individual sense of having been heard and respected. Task do not have to clever and in early sessions noticing or recording task that involve everyone in a less blaming way can be suggested as helpful to you in understanding more. They may even help the family have some new thoughts. Using the language that they have used is likely to connect you more strongly with them and is a very powerful message about your attention having been focused on them. I might say directly to the adolescent, I know your parents have probably experienced your silences as frustrating but I see it differently.

At least when they are in the family in the room there is somebody else with whom you can converse. When a silent teenager sits before you alone the onus is very much on you to find a way to help them connect. Obvious comments about how difficult it must be to be in the room, to face feelings and problems and saying how courageous they’ve been in keeping their appointment are important but may not start a dialogue. Some people can use this extended silence and I am sure that some young people find the space to reflect a very helpful experience. More often I have the sense that the young person is willing me find a key to help them pour out their words or at least start to put outside of themselves some of the turmoil they are experiencing. It’s the put out side that has left me to use techniques born from the creative therapies that are often used in group work in the individual context. These are in particular life-lines and feeling maps. If family issues are to the fore drawing family tree together or using simple outline cut out with bluetack like this I have a huge box of them all in different shapes and sizes attach on to a huge white board may create energy and be a vehicle for important discussion. I am not going to go into the details of this but this in this family little Terry struggled to make sense of his large and complex family and we used these sorts of figures in a sessions with his parents and their respective partners those his father and his current wife and his mother and her current co-habitee to help him think through some of these relationships and begin to make sense of it.

I’d like to share a case example with you. 14 year old Katy was referred by the education social worker who accompanied her and father to the first session. Katy had been refusing to go to school for 2 months, there was no domestic violence, except very early on in her childhood. Her school refusal appeared to be linked to an emotional outburst precipitated by a lesson about parenting. Her father who had resumed care at the time of her mother’s death a year earlier was at the end of his tether. He was very critical of Katy contrasted with the glowing description he gave of her younger sister. The social worker labelled Katy as disruptive in class but until this meeting had not even known that her mother had died. Katy was silent avoided eye contact and sat further down in the chair as the session progressed. My early attempts to engage her met with stony silence. Her father commented on this that it was proof that she was totally impossible. I reframed her as the careful listener and someone who is doing a lot of thinking as she emerged I complemented her on waiting to feel sure that she could trust the situation. Although she did not speak very much she did begin to look at me and agreed to meet with me on her own. At the appointed hour she arrived clearly nervous and apprehensive. She had a fixed expression and tightly closed mouth. I was already aware of her parents’ separation, mother’s cancer and subsequent death but it did not look like words would come easily. She said  she did not know where to start, sighed deeply and said, there are so many things and tailed off into defeated silence. After a short while I suggested the idea of a life line to place event in their chronological order. She took the following 2 minutes to make a sketch which looked something like this. She indicated the tension and fight in her parents’ marriage, her father’s departure, her mother’s drinking, her prolonged cancer treatment, her mother’s return to alcohol abuse during a remission phase and her movement to her father’s during the terminal phase of her mother’s illness. The life line presented a vehicle to talk about some of these events in more detail in later sessions. At the end of therapy she reflected on how important it had been to place it all before her without somehow giving one event priority. A similar technique is to suggest drawing feelings. Once provided with a sheet of paper and a range of pens young people often create an image which conveys and communicates very effectively what they feel and what they can talk about articulately, interesting if you ask them tell me what you are feeling, you get nothing. Some use stick people and events, other use colour and shapes of symbol, there is no right way. An adopted teenage boy recently taken into temporary care by social services at request of his adopted parents crumpled up his sheet into a tiny ball and threw it in the bin. I thought it was an eloquent metaphor of how he felt he’d been treated.

Humour is a very important tool with young people diffusing some of the tensions between them and their parents making it more possible to talk. Cartoons can be a helpful therapeutic aid. This one speaks to the universality of teenagers flouting their parents’ ideas about how to present themselves to the world.  ‘Come on Ilea, don’t hog the bathroom, we’ll all be late for the Earth-Ship reception. - OK mother, I am just coming. -We want to give them a good impression to go back to Earth with, don’t we dear. Mother sees her coming out of the bathroom and says, You cant’s go looking like that, you look like something from another planet.

Some of you who’ve been to the States may be familiar with Kathy. Kathy cartoons very often speak powerfully of issues of strength of connectedness and the struggle for independence in young people and young adults. Mother’s on the phone saying, Oh sweaty, phew, I spent the morning grinding cranberries by hand for thanksgiving dinner. Kathy says, Mum I’m having thanksgiving dinner with some friends this year, remember? Mum, says, I drove to the next country to find a nice fat pumpkin for your pie. Lots of people spend thanksgiving with friends and then see their parents for the real holidays. I got your grandma’s best linens out and then starching and ironing them. - It isn’t that I don’t love my family. - The butcher is picking up a special little drumstick for your puppy Electra. Kathy says, It’s just that my friends are my sort of second family. Mum says, I bought containers that match your kitchen so you can take home lots of leftovers. - I need this time with my friends, mum. - Dinner is at 4Thursday, if you don’t show up your father will croak. 4 o’clock fine, says Kathy. Dad says, That wasn’t really necessary, dear. Mum says, I know, sometimes I even impress myself.

To contrast that, because it’s often very helpful to communicate to parents that they need to think about change as much as their kids do. I am fond of Kathy. Kathy is going home Christmas and she is standing at the end of the garden gate.The second I walk through that door I am going to turn into a 5 year old, my mother will treat me like a 5 year old, feed me like a horse and then tell me my pants are too tight, my hair too long, my nails are too short, my apartment is too small, my skin’s a mess and then she’ll say, I am perfect. Then my mother would say I am so perfect that no man in the world is good enough for me and then she’ll ask me why I am not dating anyone. I know I’ll feel picked over, grilled, I know I am marching into the arms with one person who can make me grow berserk with one tincy glance. How ironic I am facing this great challenge there is only one thing I can say runs, - Mummy! - into her mother’s arms.

What is helpful depends on what the therapist is trying to achieve and on the relationships in the room. I wouldn’t suggest offering cartoon without some thought. Sometimes can ask as a prompt to raising difficult issues and lead to lively exchanges. In the wrong context I think they are patronising, insulting and will not go down very well. Young people perhaps more than any other client group challenge us to be flexible and creative at the same time as providing a safe container for their anxieties and pain. Having more ideas up our sleeve can only help us face the challenge. Thank you.

Dr. Butler: Thank you Sharon, I think one of the most important factors is personality of therapist and we of course will be lining up after this to ask Sharon to give us some help in all the things we do. Now I think we’ll go straight on if we may. Go to the last contribution which is Kathy McAuley  from the Thomas Coram Centre and she is going to tell us about of the family in leaving care.

 The Importance of Family in Leaving Care  Kathy  McAuley.

I usually in situations like this speak too fast and I know we are all flagging a bit at this point in the afternoon but I think it will probably be better if I pace myself. My name is Kathy McAuley and I actually work with Coram Leaving Care Services which is part of the Thomas Coram Foundation for Children and this part of Coram provides supported accommodation for 16 to 18 year olds and we prepare them for leaving care and moving into the community. We also provide an intensive move on and aftercare service until the young people reach the age of about 25 and thereafter as they need it. We also periodically run group work programmes and we’ve just completed group work programme for young women in foster care and young mothers in care in the London borough of Brent. We’ve also most recently set up an education support service which provides one to one literacy and numeracy teaching for young people leaving the care system who like many of them have missed out on a lot of their education.

The original title that was given to me for this session was “When the family is the care system”, which I didn’t really want to focus on and my title was “The Importance of the Family to Young People in Leaving Care”. When I got about the fourth sample of the programme it has come back to first one so I am actually covering both. First of all I want to actually start with welcoming the new Government initiate, yet one more but an important one which is called “Quality Protects” which it’s hoped will go a considerable way to improving services for looked after children and young people leaving the care system. This “Quality Protects” programme will require local authorities to approach services for children as the corporate parent. And that won’t just mean social services, that actually for the first time makes elective counsellors, health, education leisure as well as social services responsible as the corporate parent. So they all have joint responsibility for the children in their area and we are all hoping that this is an opportunity for the corporate parent to take its role seriously and to provide children in need, children who are looked after by the care system and also those leaving  it with a varied range of high quality services which could meet their and their families’ needs.

To move to the first part of this paper is “How does the care system operate as the family”, this is the one I have difficulty with because I don’t believe that the care system can really be the family for most young people looked after by local authorities. The majority of looked after children and young people still want to belong to their own families and to maintain contact with them. This is quite often despite quite serious neglect, abuse or rejection. In the words of one young person I worked with who actually opted for residential care, not foster care, he said, “I don’t want someone else’s family, I’ve got one of my own, thank you very much”. And it didn’t matter to him that there’s been all sorts of problems, it’s still his family. In my view the care system therefore should not try to replace the family but should create the conditions whereby the highest quality care is provided in partnership with parents or extended family whichever is appropriate. Unfortunately as a society we’ve not provided the type of quality care for looked after children which we would expect to provide to our own children.

According to the Department of health in 1991, it is salutary to reflect that far from remedying existing deficiencies research is showing that periods in public care have further impaired the life chances of some children and young people, because of poor educational achievement, uncorrected health problems and maladjustment. Pretty damning really, and this statements begs the question in some ways, then why take them into care in the first place. But obviously the situation is not that simple. Some children need protecting from their families or time away from them, but it would seem that some also need protecting form the care system. Unfortunately despite a number of enquires and recommendations Warner in 1992 for example, on training for staff working with children, it remains the case that most disturbed and needy young people are cared for by the people with the poorest pay and the least training. It’s not surprising therefore that so many looked after children fail to achieve their educational potential. And this is confirmed by the SSI and the OFSTED report in ’95 when they said, the care and education systems in general are failing to remote the educational achievements of looked after children.

Many carers particularly within the residential setting don’t carry out or don’t have an opportunity or not encouraged to carry out what any good parent should do, for example, they won’t go on school trips or go to open evenings, help with home work, liaise with teachers and equally importantly they rarely actually involve the natural parents or other family members to support their own child’s education while they are still in care. The Children Act 1999 was hailed as an opportunity to improve the quality of care for looked after children. Two of its central principles are listening to the needs and wishes of the young people and the continuation of parental responsibility whilst children are being looked after. Despite these principles it is still very difficult for parents to continue to carry on their role once their children have been taken into care. They don’t know quite what to do.

Carers and social workers have to give more priority and commitment to identifying ways of facilitating and supporting these relationships no matter how difficult. At Coram Leaving Care we’ve encountered many parents who’ve talked about their distress, their guilt, their sense of powerlessness when their children have been  taken into care. And they’ve often attributed their subsequent lack of contact with their children to their feelings of failure and also to their assumption that their children will be better off without them. The children in fact usually don’t agree with that. Other parents fortunately have managed to overcome these feelings and have struggled throughout chaotic lifestyles and lots of bureaucratic procedures to maintain contact with their children. In our experience on-going contact with the family can reduce the understandable feelings of rejection, isolation, confusion and anger often experienced by children being looked after away from their families. Fanshell in the 1982 US study of children in care refers to the profound insult experienced by a child whose parents seem to care so little for him that they didn’t visit to see how he was fairing. Giving children and young people the opportunity to see and talk to their family about their past can also help them to understand the situation better and to hold a more a realistic view of their parents in general.

Those young people who’ve lost contact with their families or have not received any counselling on family issues whilst being in care often construct an unrealistic and distorted view of their parents and the reasons why the y themselves were taken into care. These young people often have the greatest difficulty in forming trusting relationships in adult life. It is central therefore that social workers and carers encourage and support contact and mediate between children and their families in order to insure that the children can continue to be part of the family network. And I know this is viewed with great difficulty because of the range of reasons why children are taken into care. But there are a lot of members in the family that can still be involved.

To move actually to the importance of young people leaving care of the family we at Coram Leaving Care support and encourage the 16 to 25 year olds that we work with to re-establish or extend contacts with their parents, brothers, sisters or other extended family when they move into our supported accommodation but also when they leave and move on into their own flats. This approach was confirmed by the Children Act in 1991 when it came into force but more importantly was influenced by the expressed wishes of the young people themselves to renew family contact. Consequently young people need sensitive and careful support in working through the process of renewing contact which in times be painful, traumatic and for some ultimately disappointing. One young woman to whom I will refer as D spent several months to track her father down with the help of support work group of the project. She eventually managed to achieve this and he was some where in the Midlands and she re-established contact and then spent several weekends with him which were very positive and enjoyable over a period of about 6 months,. She then suddenly discovered that he’d moved away and had left no contact details for her. This was as you can imagine devastating for her and brought back all of the pain, and hurt and rejection which she’d felt when he first left. However despite all of this she is determined to track him down again because he is so important to her sense of identity and her need to belong.

Another young woman referred to a S has renewed contact with mother since moving into supported accommodation. Unfortunately S. is being constantly let down by her mother and whatever she does is never good enough. She herself is disappointed by her mother because she is never motherly towards her, she behaves more like a sister and also leans on S. herself for support and research shows that this is quite common for women whose daughters have been taken into care over a long period. The staff of the project experience quite a lot of difficulty at times in supporting young people in pursuing what can sometimes be obviously disruptive and unproductive relationships with family members. We therefore have to work on building up the young people’s sense of self-esteem as resilient survivors which most of them are who have ambitions and goals for themselves not just for other people. And it’s also very important to look with young people at how families function, how difficult it is to be a good enough parent, how parenting has to be learnt for some people and the benefits to he gained from good role models when you are a parent. And also how some people just can’t fulfil the enormous requirements of the parenting role. This sort of discussions help the young people gain a better understanding and also enables them to think about what they would like in terms of a parent and also how they would like to be a parent themselves. If positive family contact is re-established family members can be encouraged by the project to provide support to the young people to make the most of the placement in the supported accommodation or when they move on or out when they move on into their flat. And we found that such input from family members can actually give them a renewed sense of responsibility for their son or daughter which they lost when the young people were in care And can also obviously give the young person an extended network which they will need when they move on into their flats in the community. This input from parents has also sometimes given then an opportunity to actually acknowledge their mistakes to their children which clearly lays a good basis for future relationship developing in a more positive way.

As born out by research by B. Helen Wade on care leavers in ’95, young people we work with often want to live near their families so that they can share their social network and just pop in to see them, they also value having a home base if they are in crisis or feeling lonely. Most young people do not actually want to live with their parents and the truth is that most parents don’t actually offer this although one recent case resulted in a young man returning to his mother’s home at the age of 18 on clear adult terms and it’s actually working out very well for them. The level of contact  young people have with their families whilst they are in care is a good indicator of whether family contact and support will be provided to them after leaving care. For some young people no family contact is re-established and they are dependant on professional support which is often very limited so young people have to rely on their own personal resources and build up their own network which is quite a daunting prospect for 18 year old who may lack self-esteem and confidence and  find it hard to motivate themselves.

Whilst there have been some positive developments in the area of aftercare support to care-leavers services vary enormously and are often too short-term to really give the young people what they need. The provision of intensive and on-going aftercare support to young people until they no longer need it is a hard concept for social services to accept, it’s crucial for all care leavers but particularly for those who have no family support networks to fall back on. There is clearly need for a great deal of improvement in provision of support to children looked after to maintain a sustained relationships with families both during and after periods spent in the care system.

Under “Quality Protects” local authorities have now got to produce action plans by January 1999 in terms of what they are going to provide for services for children, the actual quality for those services. I’d like to make a few recommendations that social services prioritise support and encouragement to looked after children and young people leaving care to maintain contact with their immediate or extended families. That they devise flexible ways of supporting parents to retain contact with their children who are being looked after or leaving care. They should provide mediate and counselling re family and personal relationships for children looked after and who are moving on from care and recognise the centrality of these relationships to young people’s sense of identity and security and for longer term informal support.They should also provide on-going aftercare support which is flexible and allows for periods when young people may need respite from full independent living. We all know it’s too young to move on to your own flat to be an independent person between 16 and 18, so the level of support needs to increase rather than decrease for those young people. We hope that under the “Quality Protects” programme local authorities address these needs in partnership, in true co-operation and partnership with families and extended family members. Thank you.

Dr. Butler: Thank you very much for a very human approach to a problem which is universal and arrangements differ tremendously in every authority don’t they. There should be a guideline as to what ought to be done, not what’s being done and said.

Gail Slap: Thank you to our speakers, we have questions, I am sure, on just about every presenter, I might suggest our speakers are here, please stop them, speak to them, give them some feed back. It’s been a long afternoon, so thank you for remaining.