‘Residential Management as Treatment for Difficult Children’ by Donald W Winnicott and Clare Britton

Thursday, October 1st, 2009 Digest by Robert Shaw

Donald W Winnicott and Clare Britton (1957) Residential management as treatment for difficult children in Winnicott, Donald W The child and the outside world: studies in developing relationships London: Tavistock pp. 98-116

Chapter 6 of Part II of Winnicott (1957b) is a merging of two earlier articles by Donald Winnicott and Clare Britton, The Problem of Homeless Children (Winnicott and Britton, 1944) and Residential Management as Treatment for Difficult Children: the Evolution of a Wartime Hostels Scheme (Winnicott and Britton, 1947), describing their collaboration in supporting the staff of a number of hostels for evacuated children in Oxfordshire and the lessons they learned from the experience. The evacuation of children during the Second World War first highlighted the issues of separation and loss in children (Heywood, 1978) and the authors were called in to support children who had reacted badly to the experience of being uprooted from their homes and sent to live with a family in a different part of the country, possibly with very different standards and expectations from those to which they were accustomed.

Unlike many of the other projects described in this series, there was neither a specific view of residential care nor a long term aim to the authors’ work though they shared a common theoretical background. They, like Makarenko (1936), had a job to do and got on and did it.

Though included in The Child and the Outside World (1957b), this chapter was left out of The Child, the Family and the Outside World (1964) when the former was merged with The Child and the Family (1957a) and so was rarely picked up by residential workers after the 1960s.

Clare Britton later married Donald Winnicott and became more widely known to residential workers in England and Wales through her championing of their cause while head of the Home Office Central Training Council for Child Care in the 1960s.

Key Ideas

-           Creative rather than planned responses are the key to successful child care.

-           A healing environment rather than individual therapy is usually more effective when working with children with emotional problems.

-           A successful project has to be able to address public concerns as well as individual needs.

-           The scarcity of resources in wartime led to more support for a scheme that could demonstrate its effectiveness in addressing a social problem than could be gained in peacetime.

-           Appoint married couples and give them the freedom to manage each project as they see fit.

-           Give support to staff rather than therapy to the children.

-           Compile life stories for the children.

-           Involve every member of staff, including ancillary staff, in caring for the children.

-           Undertake a full assessment of the child’s current and family situation and experience.

-           Provide stability to the children through the stability of the staff and stability to the staff through the availability of support.

-           The quality of staff relationships is more important than the approach they take to children.

-           Children go through three phases - honeymoon, testing and stable - and testing may be both direct and indirect.

-           Children often make their most lasting relationships with those with whom they first had a conflict.

-           The 24-hour care of children is very draining.

-           Without the emotional involvement of staff children will not benefit, and without support to enable that emotional involvement to be sustained, staff will break down and children will be disadvantaged.

Contents

In the section The Evolution of a Wartime Hostels Scheme, the authors introduce the scheme for which he was the visiting psychiatrist and she the resident psychiatric social worker. The scheme evolved through their attempts to deal with the particular problems of evacuated children, assisted by the lack of rigid planning in wartime conditions which allowed flexibility and creativity in the arrangements; this in turn may have attracted a different type of person to the scheme. Since working with people demands creativity rather than the ability to implement a rigid plan, this was probably a good thing.

In the section The Developing Problem, they describe how children who failed to settle in foster homes often became anti-social and ultimately came to the attention of the courts, apart from anything else, drawing even greater attention to the problems. The initial response was to provide individual therapy for the children but it soon became clear that something more was needed; that something turned out to a number of hostels in which the proper management of the child by relatively unskilled persons, albeit informed, guided, and supported by the psychiatric team, would be the therapy.

Though the hostels were initially seen as a short-term intervention to enable children to be fostered again, it became clear that some of the children’s problems were too serious for fostering to be considered and the hostels had to become the milieu in which the children could access over a longer period the relationships and experiences that had been missing from their own homes.

A corollary of this is that good hostel work must make use of every ounce of value that may still remain in the child’s own home (p. 102).

In the section The Task, this is set out as: protecting the public and addressing public concerns, preventing delinquency, treating children and finding the best way to help them.

It the end 285 children were housed and managed in hostels, of whom about a dozen ran away. The work with the public met with mixed responses. A significant number of children who had already been before the juvenile court made no further appearances. Most children responded positively to the treatment offered, even though many revealed they had been the victims of severe emotional damage. The fact that so much anti-social behaviour was not related to the wartime situation but to the children’s emotional needs suggested ways of approaching anti-social behaviour in a peacetime context.

In the section The Scheme Grows, they describe how the scheme was set up and financed and regret that

now the war is over it is very difficult to get such things as hostels for the same children whose needs were met in wartime.

[During the war] the shortage of goods and of manpower, made prevention of damage and theft imperative, and made extra police work unwelcome (p. 105).

In the section The Psychiatric Team, they describe the management of the scheme by a voluntary committee advised by the psychiatric team. Among the decisions the committee took were to:

-           appoint joint married wardens;

-           entrust corporal punishment to the warden but to change the warden if they didn’t like the way he was using it;

-           educate staff to use corporal punishment as little as possible;

-           entrust overall management of the scheme to Clare Britton;

-           amend Donald Winnicott’s function from giving direct therapy to the children to giving indirect therapy through supporting the staff.

Clare Britton was well supported by the clerk of the local authority as well as by Donald Winnicott, enabling her in turn to support wardens in difficult decisions. Among more detailed work she undertook was compiling a life story for each child and letting them know that it was available for them, involving every member of staff including gardeners and other ancillary workers with whom the child had made a relationship in the work and supporting wardens who felt they could not longer carry on managing a particular child.

In the section Classification for Placing, the authors describe the contribution their professional training made to their work, including:

-           developing a comprehensive assessment of the child;

-           identifying what support has been available from the child’s own family and whether this can be tapped into or whether the child needs other experiences of family life,

-           identifying particular aspects of the child’s family which may have impacted on their development;

-           identifying if possible whether the child has experienced a secure attachment;

-           assessing the child’s ability to play, to persevere in constructive effort and to make friends;

-           identifying children with learning disabilities;

-           assessing bizarre behaviour which may present management difficulties.

However, the most important criterion for placing a child was not the child but the situation of the hostel at the time and, before a decision on placement had been made, the warden would be invited to meet the child. However difficult this might be, the benefits of consulting the wardens about placements always outweighed the disadvantages.

In the section The Central Therapeutic Idea, the authors write that the

central idea of the scheme was to provide stability which the children could get to know, which they could test out, which they could gradually come to believe in, and around which they could play (p. 110).

This stability was based on there being stability in the framework which supported the scheme from the Ministry of Health to the staff who cared for the children. They note that

only if the wardens are happy, and satisfied, and feeling stable, can the children benefit from their relations to them (p. 111).

The job of the psychiatric team was to supply the support to enable the wardens to provide the emotional stability which the children needed. In this context the criticism that “The hostel looks as if it were made for the staff” was not a criticism but a recognition of the work that had gone in to ensuring that the staff of the hostels stayed put for long enough for them to see children through to school-leaving age, and to the age of going out to work.

They conclude with reflections on the staff and the children. There was no particular training for hostel wardens, who came from a very wide range of occupations. They had found that the key quality was

the ability to assimilate experience, and to deal in a genuine, spontaneous way with the events and relationships of life (p. 112).

They also needed some skill, such as music, painting, pottery, etc. and a genuine love of children to see them through the inevitable ups and downs of hostel life. Being brilliant at setting up a hostel or being intelligent is no use if you then move on; even the ability to carry out agreed plans is irrelevant because a warden has to have the ability to act naturally and spontaneously in response to children’s needs. Nor did the warden’s preference for a group or individual approach, for ‘normal’ children or for those with learning disabilities appear to make any difference. The key issue was the availability of support to the warden to enable them to think for themselves and to consult with fellow wardens.

The main difficulty in dealing with anti-social behaviour was that having to maintain a consistent line might inhibit good staff from acting on their own initiative and lead them to become bored; however, staff who simply carried out instructions were not the right sort of staff to have.

As for the children, they found how “intimately a child’s sense of security is bound up with his relationship to his parents”. While the hostels could not provide anything as good as their own home, by providing a positive environment and positive relationships, they could give the child the confidence to test them as they would their own parents, whether directly or indirectly through seeing the staff’s reactions to other children’s testing.

The children went through three phases, an initial phase in which they were remarkably ‘normal’, partly because they had not begun to engage with people, a testing phase in which first the physical environment and then the emotional environment was tested, and finally a settled phase. In an unsatisfactory hostel, the second phase became almost a constant feature.

Many of a child’s relationships begin with some sort of fight or attack and the first child to be attacked by a new child would often become the child’s first friend.

Good hostels succeed not by being sentimental about children but by carefully administered justice which gradually brings them up against the consequences of their own destructive actions. Indeed, children are relieved that law and order is preserved.

However,

the immense strain for the twenty-four hour care of these children is not easily recognised in high quarters, and in fact anyone who is only visiting a hostel, and who is not emotionally involved, can easily forget this fact (pp. 115-116),

but it is essential that wardens get emotionally involved with the children. Consequently hostels need to be small so that wardens are not burdened with one more child than they can emotionally stand at any given moment. For, if a warden breaks down, the work he has done is undone and every change of wardens produces casualties among the children.

Discussion

The original versions of this paper are the first attempt to provide a comprehensive view of the relationships between managers and staff, staff and children, staff and parents and parents and children and to recognise the importance of rooting a child’s identity in its family history. They anticipate Taylor and Alpert (1973) in arguing that method is irrelevant and Wiener and Wiener (1990) in arguing that stability of relationships is far more important than planning. Like Neill (1962) and Mr Lyward (Burn, 1956) they come to recognise that the milieu rather than any specific therapy is more important in the success of residential care but go further than them in trying to describe the features of the milieu that contribute to its success.

Their own expectation that the hostels would provide short-term intensive therapy for children who could then be returned to foster homes was quickly replaced by the realisation that the emotional problems that these children had were too deep-seated to be dealt this by any quick fix and that, as Brosse (1950) was to find in her study of war-damaged children, the key to emotional survival is stable relationships with adults who receive the support to enable them to sustain a child’s testing behaviour until the child reaches the stage where they can trust them.

Though implicit in some other texts, Winnicott and Britton are the first to argue for the explicit inclusion of ancillary staff in the therapeutic task. Other texts, for example, Advisory Council in Child Care (1970), argue that such staff have a role to play in creating the therapeutic milieu but only Winnicott and Britton argue for their specific inclusion in therapeutic work with individual children who may have formed a relationship with them.

Interestingly, though married couples have been selected to run children’s establishments since the 18th century (Heywood, 1978), Winnicott and Britton only adopted this approach after the scheme had started; however, it may be better to interpret this experience as reflecting the desirability of having both male and female parental role models in an establishment as happened 25 years later at the very successful hostel in Oxford (Critchley and Fann, 1971a, b).

While the authors’ insistence on a full assessment of the child’s current and previous family situation reflected thinking at the time and their appreciation of the importance of the child’s family is also reflected in the work of Homer Lane, (Bazeley, 1928), Aichhorn (1951) and Mr Lyward (Burn, 1956), the ideas of creating a life story for the child, of being explicit with the child about the support available to them and of involving wardens in placement decisions were new.

Though both Bettelheim (1950) and Mr Lyward used involvement in peer group activities to facilitate the introduction of children into the milieu, Winnicott and Britton’s recognition of the role of indirect testing helps to explain later results such as those discovered by Millham et al. (1975) and the success of Makarenko (1936). If a child sees that children who test the establishment are got rid of, they know that the establishment may not be able to cope with their testing and so there is no use in relying on it. However, if the establishment is able to cope with continual testing, by accepting back absconders, for example, it reassures the child that it is likely to be able to cope with its anxieties and encourages the child to trust the establishment. This in turn depends on the warden being confident that they can accept whatever the child can throw at them and therefore involving them in the placement decision and then offering them support to carry through that decision become paramount to the child’s treatment and future welfare.

Though they attribute little significance to whether a warden adopted an individual or a group approach, it seems likely that the scheme succeeded overall because the range of approaches which the authors allowed wardens to establish provided a range of hostels suitable for children at different levels of development, the success of their ‘intuitive’ allocation of children to particular hostels being explained by Wolins (1973). Their insistence on staff who can be creative, albeit within a framework which is consistent for the child, rather than just follow instructions is echoed by Redl and Wineman (1952).

References

Advisory Council in Child Care (1970) Care and treatment in a planned environment: a report on the community home project London: Her Majesty’s Stationery Office See also Children Webmag December 2008

Aichhorn, A (1951) Wayward youth London: Imago First published 1925 Verwahrloster Jugend Wien: Internationaler Psychoanalytischer Verlag

Bazeley, E T (1928) Home Lane and the Little Commonwealth London: Allen & Unwin See also Children Webmag February 2009

Bettelheim, B (1950) Love is not enough: the treatment of emotionally disturbed children Glencoe IL: Free Press See also Children Webmag August 2009

Brosse, T (1950) War-handicapped children: report on the European situation Publication No 439 Paris: United Nations Educational, Scientific and Cultural Organization

Burn, M (1956) Mr Lyward’s answer London: Hamish Hamilton See also Children Webmag May 2009

Critchley, A and Fann, B (1971a) Group work with adolescent girls Child in Care 11(5), 17-23

Critchley, A and Fann, B (1971b) Group work with adolescent girls Child in Care 11(6), 11-14

Heywood, J S (1978) Children in care: the development of the service for the deprived child (Third ed.) London: Routledge & Kegan Paul

Makarenko, A (1936) Road to life: translated by Stephen Garry London: Stanley Nott Originally published as Pedagogicheskaia poèma See also Children Webmag February 2009

Millham, S, Bullock, R and Cherrett, P (1975) After grace, teeth: a comparative study of residential experience of boys in approved schools London: Human Context

Neill, A S (1962) Summerhill: a radical approach to education London: Victor Gollancz Originally published 1960 Summerhill: a radical approach to child rearing New York: Hart See also Children Webmag July 2009

Redl, F and Wineman, D (1952) Controls from within: techniques for the treatment of the aggressive child Glencoe ILL: Free Press

Taylor, D and Alpert, S W (1973) Continuity and support: following residential treatment New York: Child Welfare League of America See also Children Webmag March 2009

Wiener, A and Wiener, E (1990) Expanding the options in child placement Lanham MD: University Press of America

Winnicott, D W (1957a) The child and the family: first relationships London: Tavistock

Winnicott, D W (1957b) The child and the outside world: studies in developing relationships London: Tavistock

Winnicott, D W (1964) The child, the family and the outside world Harmondsworth: Penguin

Winnicott, D W and Britton, C (1944) The problems of homeless children NEF Monograph (1) 1ff.

Winnicott, D W and Britton, C (1947) Residential management as treatment for difficult children: the evolution of a wartime hostels scheme Human Relations 1(1) 87ff.

Wolins, M (1973) Some theoretical observations on group care In D M Pappenfort, D M Kilpatrick and R W Roberts (Eds) Child caring: social policy and the institution Chicago: Aldine

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