Listen to thisAbstract: The Maples Adolescent Treatment Centre has undertaken a shift in philosophies over the past several years. The Orinoco Care Program, a partially residential program for conduct-disordered youths and their families, illustrates the shift to using attachment theory as a basis for its program. In making the shift from controlling adolescent behaviours to connecting with the adolescents themselves, the front-line staff have had to re-examine their practice and beliefs. It has not been an easy transition, but the rewards in terms of personal agency and positive rapport with youth have been worth the journey.
The following is a response to a supervisor’s request, “What is the Orinoco program like from a lineworker’s perspective?"
In The Structure of Scientific Revolutions, Thomas Kuhn (1970) proposes that science does not develop by the gradual accumulation of knowledge but is rather a succession of peaceful, tradition-bound periods punctuated by intellectually violent revolutions and paradigm shifts. As a scientific community assimilates the new paradigm there is a shift from one world view to another. This is a suitable description for the evolution of the field of child care, especially regarding the development of the Orinoco program. The “violent revolution" that occurred was in the shift from control to connection in working with troubled adolescents. Working on the front line, as a child care counsellor, I have found this to be a challenging redirection, and one which is not without reward. The payoff has come in the form of a world view where relationships (or lack thereof) are seen as the foundation for all interactions and interventions, and where it is not only impossible to maintain the role of “unaffected, uninvolved professional," it is also undesirable. In this sense, the relationship goes beyond the traditional notion of a “professional association"; it is a connection, one based on respect, trust and mutuality.
This was a journey that required a lot of work on the part of the child care staff to become equipped, emotionally and cognitively, for the task of affiliating with these disaffiliated youths. The task of the lineworker is to provide day-to-day care and counselling for the adolescents. It is here, in day-to-day interactions, that all the pretty theories and thoughtful clinical direction is translated into action, filtered through the judgement and personality of the counsellor, and tailored to the demands of the situation. What follows are some of the inevitable questions and ponderings, and the ways in which we had to mentally prepare and repair over the course of our journey from control to connection.
Redefining and re-ordering
This new way of thinking does not include any elements that were not
present in previous or parallel programs. Rather, it is a re-ordering,
and in some ways a re-defining, of elements that is new. Other programs
are built around relationships with a small “r", and safety and
management in capital letters. In these programs, fairness and
consistency are favoured over individuality, without respect for the
context or history of the behaviour. The ability of the youth to show
independence in doing things such as chores and lifeskills outings is
favoured over affiliation with the child care team. Time spent with
staff is seen as a treat based on merit (e.g., go to school, good
behaviour and I'll take you out). The approach is very hands-off in
terms of relationships and hands-on in terms of management. The best
interests of the child, always our guiding principle, are defined in
different ways: safety and consistency (strict adherence to common rules
to maintain order), or relationship, individuality and affiliation
(seeing the behaviour in context, and developing rules and consequences
to suit the person and the act). This new approach puts relationship in
the forefront, and makes it the scaffold for all interventions and
interactions.
What is meant by 'relationship'?
A lot of words are tossed about – attachment, affiliation, mutuality,
connection – all they mean to me is that I relate to this youth as a human
being, with respect for his/her history, coping strategies, and choices.
This may sound obvious, but it is not always easy, especially when you
must respect choices that you don’t agree with, or that may lead the
youth to make mistakes. It is essential to remember that by virtue of
the fact that you are interacting with this adolescent, you have become
part of the system, the “relationship equation," and that you bring to
the relationship your own glasses, that is, your own world view and
preconceptions. The trick is to connect, not control. This becomes
easier when you remember that it is a person's right to make choices,
including mistakes, and also to live with the consequences. A “relationship" means connection, on some level.
It is helpful to temper any expectations that these relationships will compare to those we experience with co-workers, family and friends. While elements are similar – respect, honesty, availability/presence – we must not expect the kids to invest these same qualities into the relationship, or to express them in the same ways. These adolescents have often been damaged in ways invisible to the eye. Just as you would never expect a hearing-impaired person to automatically communicate with sound, or a paraplegic to move by walking, you must not expect that these kids, handicapped in relationships, initially develop one that fits our world view of what we would like a relationship to be; that they see mutuality as a natural thing; that they he able to respond to you in a way that demands trust and mutuality. It is our task to begin to teach them these concepts. This is a fact of which we constantly need to be reminded by our colleagues, supervisors and clinical teams.
Okay, so how do we relate to them?
We relate to them on a personal level. It became much easier to be human, to express anger, frustration, joy, sorrow, than to remain the unaffected therapist. That is, when a kid breaks your trust, it is liberating and within the range of the relationship to say, “I’m really disappointed. I’d like to try to trust you again, but it’s going to take some time." The trick is to realistically express yourself, in normal, human terms, without abandoning the child. To respond rather than to react. Thus, to say, “I feel frustrated that you’re yelling at me now, so I’m going to go into the office for awhile. I’d like to try to talk about this later," rather than “Don’t yell at me! Take a time out!" I see my job as being a role model, a safe person who isn’t always right, who is not unemotional, but who is safe, consistent within herself, and available. I don’t want to model aloofness and the ability to take heaps of abuse. I want to assert my rights as a person, to model boundaries and the right to expect respect and fair treatment. I also want to model appropriate emotions, including fear, anger, sadness and happiness. I want to model the willingness to work at creating and maintaining a relationship in the face of conflict; that conflict can be resolved. Conflict can be a powerful expression of attachment needs (the child testing the safety and durability of the relationship); resolution intensifies this attachment exercise.
It is important that as well as modeling, we allow the adolescents opportunities to practice these emotions and skills in a safe environment; that is, to turn the tables and allow the youth to take charge in resolving conflict (inter-peer or between staff and peer), and in expressing care and concern for peers and staff (consoling, care-taking, doing favours, giving gifts). While we may be exemplary teachers, we are often reluctant receivers, and are hesitant to accept help and support from our adolescent observers. Without accepting a certain level of vulnerability, we do not allow the child to practice mutuality; we are only doing half of the job. We are also overlooking a valuable resource. Often kids can reach peers in ways child care staff cannot; sometimes the words of support and encouragement you receive from a youth can mean more than those of your co-workers. When a child offers to make a snack for everyone, to buy you a Slurpee with his or her allowance, to talk to a peer who is in distress, or draws you a picture in art class, it is in those moments that a child is practicing what he or she has observed; the child is practising mutuality. It is important that we are aware of this, and that we capitalize on those moments. It is important that we do not summarily dismiss a child's overtures.
This sounds awfully personal ...
This model of child care necessitates an ability to interact at a very emotional level. It is important to he aware of your own issues through self-reflection and the support of co-workers. It is essential that the program respects and reinforces self-care and stress management. As always, your personal boundaries and comfort level must be respected. While at first I found the prospect of such an interaction daunting, over time, it just made sense, and it became easier to be myself than to be the detached therapist. The theory or central tenet that I most relied on was, just be there, just be you. When I started to get upset about how my approach looked to others, or how my supervisor or co-workers would do it differently, I relied on being consistent within myself. This means knowing yourself, your strengths, your prejudices, your limits, and respecting the perceptions and feedback of your peers. The cost of this model is high on an emotional level, but the payoff is in the liberation of autonomy and of “just being yourself," which is genuine.
What about countertransference?
When we enter into a relationship with individuals, we become a part of their systems. As such, we abandon the idea that we can ever be “detached observers." We become a part of the relationship equation. Countertransference is not an evil to be avoided; rather, it is an inevitability that we must be aware of and work through. This is when colleagues, supervision, clinical direction and effective self/stress-management become vitally important.
So despite the autonomy, my team is still important? What about consistency?
As stated previously, it is important to rely on the support and perception of your team. Ironically, in this model of independence, it is more important, as the personal and intense aspect of the relationship necessitates an outside view at times. It also helps to have someone tell you that you've done all you can, or that you’re doing too much – time to “back off“ – or that you have backed off too far.
Consistency and fairness is a struggle for most teams. It is often a central rule in programs that the team support one way of doing things, and that there is one rule for all. This is not only difficult to achieve, but it also precludes flexibility and individuality. What we found helpful was to strive for consistency within ourselves, and to personalize our decisions. That is, “I won’t give you the telephone right now because you just yelled at me," which is not to say that someone else may not give the youth the phone. Or, “I don’t believe in driving kids to the store for cigarettes, so you will have to find another way," which demonstrates the way you respond to this situation, and how you are likely to respond in the future. Consistency, in this model, is integrity. Of course this approach is best implemented in an environment of open communication with your co-workers. It is important that you act as individuals, and that you each know where the others stand on issues. It is also important that they are kept informed of the current situation so that they are able to support you if it is indicated (e.g., the youth is supposed to be in school, therefore I have denied him access to the phone). It is equally important to have a safe forum for exploring disagreements and confusions among team members. The adolescents need not be excluded from this process; often they may provide viewpoints or information that help in clarifying the situation, and as well, intra-team conflict may provide a valuable model for conflict resolution.
How could I be doing “too much"?
One of the most difficult aspects of this approach is defining whose needs are being met. Moving at the rate of the youth is often difficult, as we don’t feel we are doing our work unless there is a crisis or resolution. An example from my own frustration files involves a primary youth with whom I was determined to “build a relationship," explore her anxieties and plan for the future. She, however, had other ideas, few of which involved spending time with staff. I finally encouraged her (or she encouraged me) to spend an afternoon at the park. I sensed this would be my moment, where I could probe her concerns, relieve her anxieties, work for catharsis. I waited for what I thought would be an appropriate moment to “push some buttons." Somehow, the afternoon was all too pleasant; there seemed to be no appropriate moment. We returned to the unit, having had a most enjoyable experience, yet I felt like a failure. I had wasted this quality and all-too-infrequent time with her; we had not discussed one real issue. Relying on my colleagues for a dose of perception, I related my frustration and feelings of impotence. Our clinical director stated it very succinctly: “...here’s a girl who has an open mistrust and dislike for adults, yet she agreed to spend the afternoon alone with you, and enjoyed it, and you think nothing happened because you didn’t get her to talk about her abuse issues?" Sometimes just feeding the geese is enough.
It becomes necessary to do a lot of redefining. Feeding geese in the park with you maybe a great accomplishment for a kid who has trouble relating to adults. It may be enough to do this, and not to focus on her feelings or plans for the future. It isn’t important what you do, just that you be there. Every human exchange has the potential to be an intervention, including making the bed or driving to 7-11 for a Slurpee. It is important to realize that a lot of activity and entertainment in and of itself is not child care; the truest moments of affiliation and attachment-healing are in informal, personal interactions, in those times when nothing in particular seems to be happening.
Can you do too little?
Of course, by not attending to the child, not respecting his or her needs, and not respecting the process of change and development in the relationship. That is, feeding geese and going to the movie may be appropriate for the child in the beginning, but as the ground is tested, it is important to allow the relationship to move to another level. When the child feels safe to express mutuality, affiliation, attachment (perhaps in a negative way, e.g., conflict) it is important to get out of the way, and to facilitate the progression. It is this awareness of the model and process, and the attention to and respect of the child's needs, that distinguishes the child care counsellor from the caretaker.
What about working with the families and the community?
Challenging, frustrating... It is often easier to deal with the kids in isolation, imagining that the parents are monsters and that the community doesn’t care. In reality, when you do have to communicate with the families, you realize that most times it is poorly equipped people, in difficult situations, doing the best that they can. This can be difficult to accept, because you cannot deny the child's history and connection with family but you have to work with it and through it and to respect it, however dysfunctional or unhealthy it may appear. It is hard not to take on one of two roles which the families and community workers often try to give you:
a) the professional who will fix my child, or at
least, give us all the answers
b) the hot-shot who thinks she knows everything, but obviously doesn’t because the kid is getting worse
It is helpful not to direct, but to suggest and support, and to always try to respect the parent’s choices. And remember, once you take sides, you have become a part of the problem.
But what exactly are we doing, and are we making things worse or better?!
Ah, the inevitable invocations! We are providing these kids with a safe experience of a relationship. At some point they may be able to transfer these skills to other relationships, especially within their own families. We are role models; we provide an example of how to promote and maintain a relationship in the face of conflict. We model respect, mutuality, acceptance, and integrity. We are teachers. The lesson is that not all adults use power and pain, and that feelings and emotions are normal. These lessons are learned by doing, not watching or talking about, and are learned in the here-and-now rather than in the abstract future. We de-pathologize, normalize and allow them to be children. We are adding to their history, and introducing them to a new paradigm called relationships, especially with adults. We make the first stitches in their torn attachment-robes. But there is a cost, both to the child and to the counsellor. Children will experience separation anxiety and will often protest that they were set up, that is, led and guided into a close relationship only to have it terminated. This is a tough one to accept as a line staff. It helps to remember what we are doing and to make clear from the outset that this is a limited program, that there will be an end, and that it is a graduation of sorts. Accompanying rituals and transitional objects (e.g., gifts, photos, certificates, parties) will aid this explanation. In keeping with the attachment model, the primary counsellor may want to give personal gifts to his or her primary youths (e.g., a hand-painted T-shirt, handwritten note, handicraft, special rock or sea-shell). Money isn’t the thing; the personal thought is the thing. Any kind of transition period or follow-up also helps (even telephone contact over several weeks or months).
For the counsellor, it is difficult to give up these relationships, and it is difficult to abdicate what you may have come to see as your responsibility, especially to the child. That is when it is helpful to recall the child's right to his or her own decisions and mistakes. This is true for the family and community as well. This is also when the support of your co-workers is important.
While the journey is sometimes rough, and it seems as though you have lost your map and forgotten where your destination is, it is a worthwhile one; rely on your colleagues and supervisors to remind you of the goal. Connection with adolescents is a much more satisfying and instinctively humane approach than controlling them. The connection created by being genuine rather than artificial allows you to encourage change; your opinion matters. It is by guiding these adolescents through a relationship experience that they begin to learn how to establish their own connections. And in fact, it is through connection – commanding respect rather than fear – that we can accomplish the same goals that controlling seeks to accomplish.
References
Kuhn, T.S. (1970). The structure of scientific revolutions (2nd ed). Chicago: University of Chicago Press.
From: Leaf, S. (1995). The Journey from Control to Connection. Journal of Child and Youth Care, vol.10 (1). pp15-21
