Download Laura Steckley annual conference

SAIA Annual Conference:
Why Attach Matters – Please Touch
9 September 2011 Glasgow
Touch and Containment in
working with children and
families who are experiencing
difficulties
Laura Steckley
The New Centre (formerly SIRCC) /
Glasgow School of Social Work
There is a sensible way of treating children.
Treat them as though they were young
adults. Dress them and bathe them with care
and circumspection. Let your behaviour
always be objective and kindly firm. Never
hug or kiss them, never let them sit on your
lap. If you must, kiss them once on the
forehead when they say goodnight.
JB Watson, 1928
(cited in Richards, 2000)
Structure for today
• Touch
• Difficulties related to touch in working with children and
families experiencing difficulties
• Concepts of containment and holding environments
• Complexities related containment and holding environments
• Relationship between touch and containment
• Implications for practice
• Example for Illustration: Physical Restraint
Touch
• Touch is the first of the five senses to develop
• Research is becoming unequivocal as to the
developmental and ameliorative affects of
touch
• Links between touch and the development of
the hippocampus and decreased levels of
cortisol
Touch Research Institute
• Numerous studies on the impacts
of touch
– Mother infant studies
– Massage
– Comparative studies across cultures (a few slides
down)
Touch
Skin to skin contact between infants and
mothers by six hours over the first three
days after birth.
After 1 month
After 5 years
soothing
fondling
eye contact
commands
IQ tests
language tests
(Field, 2001)
Touch
Sexual abuse recovery
• 1 group received relaxation therapy
• 1 group received 30 minutes of massage 2x weekly
for a month
• Both groups reported a decrease in anxiety and
depression
• Massage group had a decrease in stress hormones
• Relaxation therapy group reported an increasingly
negative attitude towards touch.
Touch
Participants threat of and
actual electronic shock
– Handholding improved
affect regulation and bodily
arousal
– Higher quality relationship
correlated with higher
levels of improvement
(Coan et al., 2006)
Touch
• Difficulties associated with children’s
experiences of transgressive touch
– Intolerance of or ambivalence about touch
– Staff fears and a culture of suspicion
• Touch deprivation
– Sleeping patterns
– Suppression of immune system
– Increase in aggression
• Puerto Rico 180; France, 110; Florida, 2; England, 0
(Field, 2001)
Moral Panic
An intense societal
preoccupation with an event,
phenomenon, person or group
deemed to be a threat to
societal order or social values
(hence the moral part);
The perception of the degree of
threat tends to be exaggerated
(hence the panic part).
– Witch hunts, McCarthyism/Red
Scare
Touch and Moral
Panic
• Prescriptions and proscriptions
– Addressed by Ward in relation to residential child care in
1999
– Importance of seeing touch as a form of communication
• Addressed in educational settings (Johnson, 2000;
Piper & Stronach, 2008).
The touching of children in professional settings had
increasingly stopped being relaxed, or instinctive, or
primarily concerned with responding to the needs of the
child. It was becoming a self-conscious negative act,
requiring mind-bodily split for both children and adults, the
latter becoming controlled more by fear than a
commitment to caring (p.iix).
Containment
≠
Term is often
(mis)used
disparagingly to
mean keeping a lid
on or warehousing
kids.
Constrainment
Holding Environments
Holding therapy is a
controversial treatment
modality.
Holding environments is a
way of conceptualising
the care environment.
≠
Holding Therapies
Containment
•Notion first introduced by Bion
(1962)
•The infant projects the
unmanageable feelings onto
the primary care giver, who in
turn reflects them back such
that they become more
tolerable for the infant.
•Continual process of hearing
and absorbing cries of fear,
anger, hunger and discomfort
and responding accordingly
comprises early experiences of
containment.
– Very strong parallels with
processes of attachment
Containment
• Early, ongoing experiences of
containment enable the
development of thinking to manage
experiences and emotion.
• When individuals’ experiences of
containment are inadequate or
significantly interrupted, cognitive
and emotional development are
affected.
• Uncontainable feelings and
experiences are normal and arise
throughout the lifespan.
Emotional Holding
• Derived from Winnicott (1965)
• Connection with child’s sense of
being held during infancy, both in
caregivers arms and in a safe
environment.
– Makes possible emotional development.
• This whole experience of being
physically and emotionally held by
caregivers is referred to as the
Holding Environment
– Within this the child develops trust,
learns to identify thoughts and feelings,
and develops the capacity to think,
symbolise and play.
The notion of holding is central to effective care
giving relationships
Holding environments:
• Create reliably safe boundaries
• Offer a protective space
• Enable children to experience
themselves as valued and secure
• Is associated with a secure base
(Kahn, 2005)
Containment and Holding
Environments
• Both Bion and Winnicott applied their respective
models to the relationship between therapist and
client, stressing the importance of metaphoric
containment or holding as part of the process of
healing and recovery.
• These concepts have been subsequently applied to
a range of relationships and settings, including
education, social work, consultancy and even
business.
Containment involves:
• Caretakers ‘absorbing’ the
experiences of those seeking
their care to:
– Better understand ‘careseekers’’
needs and how to meet them
– Contain parts of careseekers’
experiences, helping them to
identify, verbalise, and make
manageable those uncontainable
feelings.
(Kahn, 2005)
Containment
This concept can also be applied to the more
complex network of relationships amongst
and between staff and children in residential
child care.
– Involves directly addressing via verbal
interpretation
– Also involves the use of daily activities, transitions,
leisure time, and even the physical environment
towards the…
– …development of a containing atmosphere in
which children feel (over time) accepted,
respected and understood.
(Ward, 1995)
Containment—
the role of a
therapeutic milieu
A therapeutic milieu can assist the client
in holding or containing her painful
emotions, allowing her to express internal
conflict in a way that can bring about a
greater sense of personal responsibility.
Containment
•Is never static
•Is complex
•Has literal and metaphoric dimensions
Containment
Challenges include:
•Holding the literal and the metaphoric in mind
at the same time
•Differentiating own feelings from those
absorbed from young person
•Counter-transference
Diminished energy, insight, increased focus
on control, emotional unavailability,
provoking and/or punitive interactions
Containment for
Containers
Needed not only for the demanding and
complex work of meeting children and
young people’s containment needs, but
to enable carers to respond to
complexity, uncertainty and risk…
…particularly in the current risk-averse,
increasingly bureaucratic approaches to
practice (Ruch, 2005).
Unit Managers

Pivotal role in providing containment

Increasing fragility of organisations due
to continual restructuring and
redeployment of staff
– Diminishes organisational containment
– Increases pressure on individual managers
as containers
Containment for
Containers
Necessary nesting function of containment
Systems of
Staff Support
Staff
meetings
Containing relationships
between staff and
young people
Consultancy
Other functions
of management
Supervision
Ruch’s Holistic Containment
Holistic containment
• Emotional containment
(feeling containment)
• Organisational containment
(doing containment)
• Epistemological containment
(thinking containment)
Rethinking areas of practice
• Relationships
• Use of self
• Child centredness
Rethinking areas of practice
• Managing challenging
behaviour
• Control
• Touch
Relationship between touch and
containment
• Touch can be an important element of a containing
experience;
• It can also create anxiety, both for the child/family
member and for the practitioner;
• The clarity of our thinking has been distorted by
uncontained anxieties related to touch (and to
abuse, particularly paedophilia);
• Practitioners’ need for touch rarely, if ever,
addressed.
Physical Restraint:
An illustrative example
• Defined as “an intervention in which staff
hold a child to restrict his or her movement
and [which] should only be used to prevent
harm” (Davidson, et al, 2005, pviii).
• Embodies extremes of both
containment and touch.
Physical Restraint:
An illustrative example
The Study
• Funded by Save the Children, Scotland
• Aim to explore experiences of staff and young
people in residential child care of physical restraint
• 41 Staff & 37 young people interviewed
• 20 establishments involved in study
– Care homes, secure settings, and residential schools
– Local authority, voluntary and privately funded
organisations
Physical Restraint:
An illustrative example
Findings related to touch
•
•
•
•
Touch as risky: staff
Touch as aggression: young people
Aggressive touch and staff
Physical restraint, touch and catharsis
Touch as risky: Staff
• Risk of further escalation
• Risky in other ways as well
Touch as risky: Staff
Neil (staff): I still think there’s a [place] for
hands on in a comforting way as well…And
I’m comfortable enough with that if I know the
young person, although I realise, you know,
there’s a lot of issues about and, you know,
there’s risk there as well. You don’t do it when
you’re on your own and you make sure it’s
not square on contact that could be deemed
sexual in any sort of way.
Touch as risky: Staff
Ilene (staff): I think it’s risk assessment, totally risk assessment.
I think the same ah, um, like a comfort hold, which I use
quite a lot now and that’s more of a….“come on,” you know,
kind of a side hug/
Interviewer: Right/
Ilene: /side hug, um, appropriate, having people there when
you do it, but it can de-escalate a person so quickly because
half the time they want to cry and they don’t want to
fight…and I think women have a better feel of doing that, to
girls and boys because we’re seen in that role more. Aye, I
think if a guy walks over to a guy and goes up to them it
would be like [roaring sound].
Touch as risky: Staff
Maureen (staff): Now what is not part of the guidelines is that
the boy is still in the physical assist position while we’re
going through that process. But sometimes we’ve found that
that’s the best time to do it…He might want to talk and if he
wants to talk then we might say, “Do you want to get up and
we’ll talk”? “No, I want to stay here.” So then we’re going to
do it down there. But the guidelines are that the young
person should get up on a chair doing it, but we feel, I feel if
that’s where he feels comfortable then, if he’s on his
stomach, face down then quite often they’ll just put their
arms out. We stand at the side, either side, more often than
not. Absolutely no body contact, but we’re sat either [side]
and we’ll talk.
Touch as aggression: young people
Davy (young person):…nobody on this earth
should be allowed to either, shouldn’t be able
to touch us at all.
Touch as aggression: young people
• Coleen (young person): I don’t think they
should do it too hard because they don’t
know how it feels to be sitting in the middle/
• Interviewer: /ah ha/
• Coleen: /getting all the hurt and that…’Cause
once I got restrained and I came out my
restraint and my arms were all red.
Touch as aggression: young people
Interviewer: Do you think that the staff, you said earlier that the
staff are doing the best they can, but they could do better,
and during a restraint, do you think the staff are doing the
best they can but maybe just get a bit too/
Ryan (young person): Frustrated.
Interviewer: Yeah, or do you think they are purposely trying to
be too hard, too intense during a restraint? Like, I don’t
know/
Ryan: Teach them a lesson.
Interviewer: Sorry?
Ryan: Teach them a lesson, so they don’t do it again.
Interviewer: Do you think that they, yeah?
Ryan: I’ve always thought it.
Aggressive touch
and staff
Richard (staff): The boy that broke my nose didn’t make me
angry…We had a great relationship before, but it’s better
now
Interviewer:…How did you account for it being better after
him breaking your nose?
Richard: Because I think he expected me to, possibly to hit
him when he was on the ground…But I went through it
with him and he’s quite protective of me now. It’s quite
strange…
Interviewer: Did he ever apologise to you?
Very grudgingly. But the main apology was physical. He
would come and sit beside and talk to me. He gave me a
little key ring, so he did it that way…I think he thought,
“Well all males are like that.”…So he found that they’re
not. And that’s maybe why it’s better now. The
relationship’s better now. Much, much better.
Physical restraint,
touch and catharsis
Jean (staff):…part of it is because particular young people
who had at that time, their emotional needs were so
great that they almost encouraged restraint so that, I
know that doesn’t sound very good, but they did
encourage restraint. They pushed things to an extent
where we could do nothing else but restrain them…Their
emotional needs were not being met by anything else
and they needed somebody to hold on to them and say,
“Tell me what is wrong.” Now my preference would to be
able to go up this person at any point and give them a
hug and say, “Tell me what’s wrong,” but I feel with some
of the young people [in] particular they have had, they
have been so unused to that kind of pressure of
somebody actually saying, “Tell me what’s going on.”
They have been abused. They don’t know how to
verbalise their feelings without having first being through
a physical fight almost.
Physical restraint,
touch and catharsis
Emma (staff): One of the ones that I key worked, I mean
she admitted, because she kept trying to get restrained
and we weren’t. We just kept not, but then she just kept
upping, she would do something more violent and more,
so you didn’t have any choice than to kind of put a hold
on to her. But when we talked about it, she said it was
just because it meant, like, somebody was physically
holding her and that’s what she really missed. She
missed somebody actually like physically, physically
holding her…[it] just seems bizarre because it was
horrible to go through to actually get that. And we tried to
kind of show her, well just ask, or we would come up with
different ways if that’s the only reason you’re doing it,
then you shouldn’t have to go to that kind of extreme to
get a hug or something.
Physical restraint, touch and
catharsis
Jason (young person):… there’s times where
you need to be restrained and you feel
yourself, there’s some boys in here in the,
even, see in [name of establishment] there’s
boys that speak to each other and like say,
aye I feel like I like getting restrained to take
my anger out away.
Physical restraint,
touch and catharsis
Sharon (young person): Some kids just need to be
held to comfort them.
Interviewer: As a comfort thing?
Sharon: Yeah.
Interviewer: So sometimes do they get held when they
haven’t, when they’re not putting anybody at risk,
but they just need the comfort of being held? OK.
Sharon: Well they won’t, but like you have to mad
before they can do it.
Physical restraint,
touch and catharsis
Interviewer: Oh, I see. So maybe a kid really just needs the
comfort, but they have to kind of go into that ‘putting at risk’
place to be able to get the hold. Aye? That, what do you
think about that?
Sharon: Well I’ve done it a few times.
Interviewer: Yeah? That’s really honest. If there was a way to
be able to get that need met without having to go mad,
would you have liked to have had a way to do that?
Sharon: Hmm [affirmative].
Interviewer: Yeah?
Sharon: I don’t know how to for, [pause] you don’t, you need to
get all your anger out and then you just go mad and then you
need to be held.
Physical Restraint:
An illustrative example
Conclusions
• Touch being seen as risky linked with wider context
• Potential for physical restraint to be legitimized over
other forms of touching
• Prevalence of pain warrants deeper consideration
• Potential for therapeutically containing processes to
reduce or eliminate the need for physical restraint
• Containment for staff required for this to be possible
Piper and Smith (2003, p. 883) suggest that
child care workers develop ‘distorted
cognitive schemas’ as a result of constant
fears of accusation. In such defensive
climates, ‘affectionate or supportive touch
becomes interpreted as extraordinary and
abusive, whereas aggressive touch is
regarded as the ordinary’.
So how might we
proceed?
With meeting our own containment
needs?
With meeting the
containment needs
of Children and
Their Families?
With meeting
the containment
needs of our
staff?
So how might we
proceed?
To touch?
When, why, how?
Or not to touch?
Touch cannot be sensibly separated from the
context of relationships…
References
• Bion, W.R. (1962). Learning from Experience. London:
Heinemann (1967).
• Coan, J. A., Schaefer, H. S. and Davidson, R. J. (2006) 'Lending
a hand: social regulation of the nueral response to threat',
Psychological Science 17(12), pp. 1032-1039.
• Field, T. (2001) Touch, Cambridge, MA, The MIT Press.
• Johnson, R.T. (2000). Hands off! The disappearance of touch in
the care of children. New York: Peter Lang.
• Kahn, W.A. (2005) Holding fast: The struggle to create resilient
caregiving organizations. East Sussex, Hove: BrunnerRoutledge.
• Piper, H. and Smith, H. (2003) ‘“Touch” in educational and child
care settings: Dilemmas and responses’, British Educational
Research Journal, 29(6), p. 879–94.
• Piper, H. & Stronach, I. (2008). Don’t touch! The educational
story of a panic. London: Routeledge Taylor & Francis Group.
• Richards, G. (2000). Putting psychology in its place: A critical
historical overview. Second Edition. London: Routledge .
References
• Ruch, G. (2008) 'Developing "containing contexts" for the
promotion of effective work: The challenge for
organisations', In B. Luckock and M. Lefevre (eds),
Direct Work: Social work with children and young people
in care, London, British Association for Adoption and
Fostering.
• Ward, A. (1999). ‘Residential staff should not touch
children': Can we really look after children in this way? In
A. Hardwick & J. Woodhead (Eds.), Loving, hating and
survival: A handbook for all who work with troubled
children and young people. Aldershot: Ashgate Arena.
• Ward, A. (1995). The impact of parental suicide on
children and staff in residential care: a case study in the
function of containment. Journal of Social Work Practice,
9(1), 23-32.
• Winnicott, D.W. (1965). The maturation process and the
facilitating environment. London: Hogarth.
[email protected]
• Steckley, L. (2011). Touch, physical restraint and therapeutic
containment in residential child care. British Journal of Social
Work, advanced access published July 7, 2011, 1-19.
• Steckley, L. (2010). Containment and holding environments:
Understanding and reducing physical restraint in residential
child care. Children and Youth Services Review, 32(1), 120128.
• Steckley, L. (2009). Therapeutic containment and physical
restraint in residential child care [Electronic Version]. The
Goodenoughcaring Journal, 6, n.p.
CYC-Online Monthly Column
Steckley On Containment
• November 2010
• December 2010
• March 2011
Steckley on Touch
• November 2009
• December 2009
• March 2010
• May 2010