Therapeutic Residential Care for Children and Young People
An Attachment and Trauma Informed Model for Practice
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Extracts from Hannon, Wood and Bazalgette 2010 are reproduced
by permission of Louise Bazalgette, Demos.
Figure 1 from Prilleltensky, Peirson and Nelson 2001 on p.23 is
reproduced by permission of Isaac Prilleltensky.
Figure 10.1 from Friedman 2005 on p.242 is reproduced by permission of Trafford Publishing.
Figure A2.1 from Prilleltensky 2006 on p.260 is reproduced by permission of Isaac Prilletensky.
First published in 2012
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Copyright © Lighthouse Foundation 2012
Foreword copyright © Brian Burdekin 2012
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Library of Congress Cataloging in Publication Data
Barton, Susan, 1951-
Therapeutic residential care for children and young people : an attachment
and trauma-informed model for practice / Susan Barton, Rudy Gonzalez, and
Patrick Tomlinson ; foreword by Brian Burdekin.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-84905-255-9 (alk. paper)
1. Child psychotherapy--Residential treatment. 2. Adolescent psychotherapy-
-Residential treatment. I. Gonzalez, Rudy, 1973- II. Tomlinson, Patrick,
1962- III. Title.
[DNLM: 1. Stress Disorders, Traumatic--therapy. 2. Adolescent. 3. Child
Abuse--therapy. 4. Child. 5. Residential Facilities. WM 172.5]
RJ504.5.B38 2012
618.92’89--dc23
2011017938
British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84905 255 9
eISBN 978 0 85700 538 0
Dedication
This book has been inspired by the love that we have for our own children and the
children that we work with. Who constantly inspire us to lead from the heart. We
hope that this book inspires the community to respond to every child in a way that
fills them with a sense of love and belonging.
Rudy
To Patricia, Lucas, Thalia and Giselle for your love and support. To my parents
for instilling in me the importance of family and community and a belief in the
value of education.
Susan
To my beloved grandchildren Sienna, Tahnee, Maia, Isaiah, Asher, Ethan, Jedd,
Yasmin, Anastasia, Eloise, Otelia and to my grandchildren yet to be born to our
family. Good enough reasons to change the world. I am thankful knowing that you
belong to such devoted and loving parents. I long for each moment with you. How
blessed I am to have you all in my life. Remember to always lead from the heart.
Patrick
To my daughter and son, Patsy and Daniel.
Contents
Foreword by Brian Burdekin 11
Acknowledgements 13
Authors’ Note 15
Introduction 17
What is child abuse and neglect? 23
The cost of abuse 26
The need for early intervention, treatment and prevention 28
CHAPTER 1. The Importance of a Theoretical Base 30
The relationship between theory and practice 31
Theory in the caring professions 33
Psychodynamic thinking 35
Psychodynamic concepts 36
The relationship between the organization and therapeutic task 41
The treatment approach 42
Attachment and trauma-informed theories 43
The influence of Winnicott on therapeutic residential care 44
Individual, family, community and societal wellness theory 45
Conclusion 47
CHAPTER 2. Trauma-Informed Practice 48
How traumatization develops in childhood 49
Trauma causes hyperarousal and fear in children 53
Childhood trauma reduces the brain’s capacity to think and
regulate emotions 54
Trauma disconnects children from relational resources 57
Trauma restricts the attention capacity of children 58
Trauma-based behaviour has a functional purpose 58
Trauma restricts children’s ability to deal with change 59
Trauma undermines identity formation in children 59
Trauma affects social skills development and impacts on peer relationships 61
The impact of trauma on the child’s internal working model 61
Relationship and attachment difficulties 63
Physical wellbeing 63
The basics of trauma treatment 64
CHAPTER 3. Therapeutic Relationships 68
Beginnings 68
Information gathering and assessment 73
The intake process 74
Attachment 75
Secure base 79
Commitment 81
Continuity of care 82
Working with loss 84
Role modelling 87
Personal growth 87
Creating capacity for relationship building: one-to-one time with children 87
Unique needs 91
The importance of the relationship when challenging behaviour 92
Challenging behaviour as a sign of hope 92
The role of touch in the healing process 100
Consequences vs punishment 102
Promoting responsible children: empowerment processes 105
Participation of children and young people in the organization 107
CHAPTER 4. Demands and Rewards of the Work:
Staff Support 111
Working with challenging and aggressive behaviour 112
Physical and emotional wellbeing 115
Working with anxiety 118
Communication challenges 120
Therapeutic supervision: working with feelings 122
Safety and containment 126
The impact of trauma work on our own memories and experiences of
childhood 131
CHAPTER 5. The Home Environment 135
Home aesthetics 140
Encouraging play and curiosity 142
Privacy and security 144
CHAPTER 6. The Holding Environment and Daily Routines 147
Routines, limits and anchor points 149
Daily programme 151
Use of television and computers 152
Free time 153
The importance of food in the healing process 153
Bedtime and waking routines 161
Play 162
Celebrations as a sense of belonging 168
CHAPTER 7. The Organization and Community 170
The language of the organization 172
Trauma re-enactment and its impact on the organization 174
Management and the therapeutic task 176
The Lighthouse Foundation as an open system 180
Leadership 184
Authority 187
Managing change 188
The organization’s vision 191
Sense of community 193
Sense of family and home 194
Organization as family 197
Local community 198
Community committees as a containing membrane 199
Collective wellness 201
CHAPTER 8. Therapeutic Group Processes 202
‘I feel like saying’ process 205
Shared history: culture passed on through stories 209
Strong culture 210
Child safety 211
Reflective practice 211
Emotional intelligence 213
Emotional wellness 213
Transparency and openness 214
Family meetings 214
Combined family meetings 221
Whole family meetings 221
Youth forums 221
Clinical supervision (relationship between carers) 222
Clinical peer supervision (carers’ meeting) 223
Mediation processes 224
CHAPTER 9. Moving On: Transitions, Aftercare
and Outreach 226
Transition as separation experience 227
Life membership 229
Transitional planning and transitional objects 230
Transition celebrations 231
Stepping stones: transitional programmes 232
Assessing readiness for transition 233
Carer relationship beyond transition 234
Aftercare programme 235
Outreach 236
Children returning to work with the organization 238
CHAPTER 10. Outcomes-Based Practice 239
Outcomes-based approaches 241
The need for evidence 243
Measuring outcomes 245
Challenges in measuring outcomes 247
Potential benefits and value of developing an outcomes-based approach 250
Appendix 1: Susan’s Story 253
Appendix 2: The Lighthouse Therapeutic Family
Model of Care 259
About the Authors 265
References 267
Subject Index 279
Author Index 285
Foreword
More than two decades ago, as Federal Human Rights Commissioner of
Australia, I chaired the National Inquiry into Homeless Children. We
recommended specific strategies for a co-ordinated and effective national
policy to protect the most vulnerable and disadvantaged young people in
our community. The government responded with a $100 million package of
various initiatives – and the wider community could no longer ignore the issue.
However, notwithstanding Australia’s wealth, outstanding work by
several individuals and community groups, further government initiatives,
and mounting evidence of what works in practice, thousands of vulnerable
children still receive sub-standard care and the number of homeless young
people has increased. In 1989 we estimated that 25,000 children and young
people under the age of eighteen were homeless; in 2011 it is estimated that
there are 50,000. In 1989 there were 14,000 children and young people in
state care; by 2006 there were 27,000; by 2009, 34,000; and by 2010 there
were 35,895.
We continue to see high levels of complex trauma experienced by many of
these children, due to their abuse and neglect, and we continue to see 35 per
cent of children in state care enter homelessness within the first twelve months
of ‘leaving care’. These figures are a national disgrace. In many cases the basic
human rights of these children are still being violated – or simply ignored.
The authors of this book clearly demonstrate that ‘trauma-informed’
approaches, focusing on community reintegration and providing meaningful
attachments for children and young people, have positive outcomes and can
end the cycle of abuse, neglect and homelessness. Their approach and, more
importantly, their results give real meaning to the rights all children should
enjoy.
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Therapeutic Residential Care for Children and Young People
The book provides a theoretical as well as practical understanding of all
the elements involved in a successful model of care for traumatized children.
The authors, with over 70 years of relevant work between them, relate
their extensive personal experiences, those of other professionals working
with traumatized children, and the stories of children themselves who have
successfully recovered from childhood trauma. The result is a comprehensive
account of what actually works, which could potentially provide a blueprint for
both governments and communities working with homeless and at-risk young
people.
This book clearly sets out the Lighthouse therapeutic approach to working
with traumatized children in ‘out of home care’ and homelessness. It promotes
something close to my own heart: the critical importance of ‘family’ and a
sense of community in healing trauma and providing a better future for our
most vulnerable children and young people. The authors have my thanks – and,
I hope, your attention.
Professor Brian Burdekin BA LLD LLM,
International Human Rights Adviser,
former Federal Human Rights Commissioner of Australia
12
Acknowledgements
To the young people who shared their stories for this book, and all the children
and young people who have trusted us to share their stories over the years, and
have given us the gift of being part of their lives.
We wish to pay special tribute to Vicki Vidor. Vicki has been our staunchest
supporter and lifelong friend, who from the beginning realized the importance
of the young people’s stories being told and of providing a voice to the many
children around the world who have experienced abuse and neglect. She knew
that homelessness was more than a lack of shelter but also included a lack
of family, social and material supports that most of us take for granted. Her
concern matched our own – she knew that more needed to be done. Vicki
became intimately involved in our dream and through her unwavering support
of our Therapeutic Family Model of Care we have been able to advocate for
a more loving response to those who have missed out on the love and care of
a parent. Your support and encouragement to write this book creates further
opportunities to share our approach with others throughout the world. Vicki,
we will never have the words to describe the depth of gratitude that we have
for you and your support of our work with abused and traumatized children.
You can be assured that your gift to humanity has been large and meaningful
and has provided children with their fundamental right to live in a safe and
loving home. You continually give of yourself wholeheartedly and for that
the Lighthouse community has been blessed. The world is a better place for
having you in it. We hope that our appreciation of what you contribute to these
children sings through these pages. Your family must be proud of you – as we
are.
To all the countless people who have supported us over the years with
love and inspiration and expanded our horizons, our heartfelt gratitude. To all
the members of the Lighthouse community: our young people, carers, direct
and indirect care teams, volunteers, community committees, corporate partners,
trusts and foundations, community partner organizations and board of directors.
And especially to our beloved families who over the years have contributed
to our understanding of the need for love and the importance of family: Trish,
Giselle, Lucas, Thalia, Mirta and Adalberto, Cardoso and Gonzalez family,
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Therapeutic Residential Care for Children and Young People
Brett, Cooper and Deb, Chandima, Renee and Kane B, Kane and Diana, LaToya
and Chris, Jacob and Letetia, Michael and Terrie, Mark and Paul.
To the many teachers, mentors and colleagues that we have had in our
years of study and work who have inspired and have expected more of us and
encouraged our passion for our work. We are sorry we can’t list everyone’s
names, but all of you deserve our gratitude. We will name those who have
been pivotal in our professional development including: Dr Jo Grimwade, Dr
Isaac Prilleltensky, Heather Gridley, Dr Renzo Vittorino, Dr Denise Charman,
Dr Alison Griffiths, Dr Adrian Fisher, Greg Lolas, Dr Sarah Crome, Dr Colin
Riess, Kane Bowden, Leo Maher, Cynthia Johnson, Lilly Cabrillo, Bernie
Durkin, Tymur Hussein, Les Terry, Emma Sampson, Briony Kercheval, Helena
Culbertson, Margot Cairns, Jane Jordon, Jim and Suzanne Fizdale, John
Whitwell, Chris Knight, Adrian Ward, Olya Khaleelee, Clive Firman, Paul van
Heeswyk, Mary Walsh, Dr Linda Hoyle, Dr Neil Thompson and Quinn Street
Philosophical Society.
And to those who read the manuscript and provided much valuable
feedback and support: Patricia, Cheyne, Jorge, Jo, Kane, Kristen and Sarah.
Our literary and legal support team which has included Jason Watson and
Hayley Sher at FAL Lawyers, Mark Krenzer and Dr Lisa Symonds at Clayton
UTZ, Anne O’Donovan and Brian Doyle.
Jessica Kingsley Publishers, for their belief in the book and their commitment
to supporting the publication. In particular, Stephen Jones, Caroline Walton
and Alexandra Higson.
We wish to acknowledge each other, for the bond that we have developed
through the journey writing this book and which will last a lifetime. The
collaboration to put into words so elegantly what we feel and value about the
way we care for the most vulnerable children in our community is a true gift.
14
Authors’ Note
The stories in this book are true and in order to ensure anonymity and protect
privacy we have altered identifying details. The children’s names have been
changed as have the names of carers.
The stories provided are a small number of the many that we have heard
over the past thirty-five years. Collectively we have worked with over a
thousand children and adults who have endured severe neglect and abuse in
their childhood at the hands of those who should have loved and protected
them. We hope that the courage and resilience of the children whose stories
we have told, and the many others who have similar stories, shine through in
this book.
15
Introduction
A child‘s life is like a piece of paper, on which every passer-by leaves a mark.
Ancient Chinese proverb
The aim of this book is to provide an understanding of childhood trauma, how
it impacts on child development, and how we might work with traumatized
children to facilitate recovery. The book is specifically about working with
children in the entirety of day-to-day life. For children who have been severely
traumatized by abuse and neglect, often from infancy onwards, every aspect of
their life needs to be considered. Every event in everyday life is an opportunity
to encourage therapeutic change. The authors have over seventy-five years’
experience between them of working with traumatized children and young
people. This experience has informed the approaches and beliefs expressed in
this book.
In particular, the authors refer extensively to our work at the Lighthouse
Foundation, which Susan Barton founded in 1991, after sixteen years of
working with traumatized children in her own home as a foster carer. However,
in doing so, it is our intention to highlight theory and practice which is
universal and can be used or adapted by anyone working with children in
therapeutic residential care and other settings, such as foster care.
We have developed a ‘trauma-informed’ approach that influences every
aspect of our work: the work with individual children; the work in groups; the
way we organize the home environment and daily routine; the way we run our
organization; and our relationship with the wider community. Our theoretical
approach is particularly influenced by community psychology, psychodynamic,
attachment and neurobiological trauma theories. Therefore we take account
of the individual psyche, the social and the biological to create a holistic and
integrated approach to care and treatment.
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Therapeutic Residential Care for Children and Young People
We draw upon some of the concepts developed in therapeutic communities
over the last fifty years or more and combine this with contemporary
neurobiological research on child development. We believe it is necessary for
an organization, like the Lighthouse Foundation, that provides therapeutic
residential care and treatment to have a coherent theoretical model. This enables
the whole team and organization to have a shared understanding of trauma
and the approaches used; use the same language; and provide the consistency
that is so important for traumatized children. It is particularly important that
the organizational culture, processes, leadership and style of management are
compatible with the therapeutic approach.
Throughout the book we talk of the traumatized ‘child’ and ‘children’,
whilst the work we are talking about is often with teenagers who we normally
call ‘young people’, we have used the words ‘child’ and ‘children’ for a number
of reasons. The words are commonly used internationally and therefore it
makes for consistent and easier reading.
Often we are talking about trauma that has occurred in early childhood and
infancy; so much of what we have to say about the treatment of trauma is also
relevant to younger children. We also draw on the experience of the authors
in working therapeutically with younger children. We refer to ‘looked-after
children’ and children in ‘out of home care’. There are different definitions of
these terms in different countries. For example, when talking about children
in out of home care in Australia, it refers to children who are in the care
of the state. In this book we have used the term more broadly, referring to
children who are unable to be cared for by their families of origin, and are now
residing in other care environments – foster care, kinship care, residential care,
therapeutic residential care, homelessness services and other forms of care.
The term ‘carer’ is also used extensively in the book. We understand there
are people that provide care to children who may not refer to themselves, and
are not referred to, as carers, for example residential youth workers, youth
workers, social workers, child care workers, and various other roles. When we
refer to carers we are talking about those who provide care to children as an
alternative to the parents of origin. This book is as relevant to foster carers and
professional carers as it is to other workers who provide care to children in
out of home care. Finally, throughout the book we tend to use specific gender,
he or she, for ease of reading rather than continually using ‘he/she’. Usually
the role or person we refer to could equally be male or female and we are not
intending to be exclusive in any way.
In writing this book there are three specific dilemmas we would like to
draw attention to. First, as we are particularly focused on trauma, its impact on
child development, and how to treat it, there is a danger that we give a slanted
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