Are you managing? The effective management of anxiety in residential settings

Iain Macleod

Introduction
Becoming a manager in residential child care is never an easy transition to make. The management task presents constant dilemmas and challenges. The demands and complexity of the task when they are recognised can often be framed in a negative way as the following quotation demonstrates:

Research evidence is very clear as to the positive influence on all aspects of the care experience of clear, knowledgeable and sensitive leadership. But the supply of such individuals is limited. (Author’s emphasis) (Clough et al., 2006, p. 56).

Working in, and managing the tasks of, a residential care setting presents its own particular challenges. Some of those challenges as they relate to the management task are explored in this paper. Specifically there is a focus on the management of anxiety and the impact that this has on the day-to-day life of a residential care setting. Central to the discussion is an acceptance that working with young people who are vulnerable can evoke feelings of anxiety in staff. Most practitioners and managers will be able to identify with the following:

Inherent in every task – and institutions are set up to perform specific tasks – there is the anxiety, pain and confusion arising from attempting to perform the task; and institutions defend themselves against this anxiety by structuring themselves, their working practices and ultimately their staff relationships in such a way as to unconsciously defend (sic) themselves against the anxiety inherent in the task. (Obholzer, 1987, p. 202).

This paper seeks to discuss institutional anxiety in residential child care. It will examine the roots of anxiety from a theoretical perspective, and offer some suggestions for its management in the care setting.

The roots of anxiety in residential care
The intensity and complexity of working and managing in a residential setting are features which separates it from other areas of social work. Clough, Bullock and Ward (2006), in their review of the literature, outline the “extraordinary levels of skill and knowledge” required by staff caring for children away from home (Clough et al., 2006, p 105). Such skills and knowledge should include frameworks for the management of anxiety. The idea that working in a residential child care setting may provoke anxiety and that this anxiety has a significant impact on the effectiveness of the work with young people deserves further exploration. One theoretical perspective which is helpful here is rooted in psychodynamic theory, in particular the work of Isabel Menzies Lyth (Menzies Lyth, 1988). Menzies Lyth worked primarily in health care and demonstrated how medical staff unconsciously protected themselves from the stressful nature of their work by over-professionalising the task. This led to the depersonalisation of patients. Her work drew heavily on psychodynamic theory. Other more contemporary proponents of this view are Obholzer and Roberts (1994), Gabriel (1997), Huffington et al. (2004). Psychodynamic perspectives in residential child care have had an important role within the practice literature and the development of the profession (Lanyado, 1988; Ward et al., 2003). While these perspectives are not presented as the only way in which we can understand our work, they do provide one of the ways in which we can start to look at the impact that working in a residential setting may have on staff, managers and the young people.

As Menzies Lyth and others have demonstrated, there is a danger that professionalism within the workforce may be interpreted and used as a protective mantle. Furthermore, the worker may not be fully aware that this is happening, as defences against anxiety often work at an unconscious level. Thus, staff may confidently state within supervision or a team meeting that the work does not affect them personally because they have learned during their induction and training that they must not be judgemental, that they must adopt anti-discriminatory practice, and that it is important to stay within professional roles and boundaries. While the expression of an appropriate value base and practice located within an anti-discriminatory framework is commendable, it does not adequately address the individual experience of the worker, nor does
it address the unconscious impact of the intensity of residential work on the staff team.

Public and professional assumptions about young people in residential care
It can be a useful exercise to consider the way in which young people who are placed in residential care can be described, in both professional reports and in the media (Clackson, Lindsay and Macquarrie, 2006). In the media discourse, detrimental terms are often used in relation to children in care. Descriptive terms such as “dangerous”, “in crisis”, “out of control”, “violent”, and “disturbed” have been used. What is important here is the impact that the use of these terms can have on the staff team. If such messages exist in the discourse, practitioners will absorb these both at a conscious and unconscious level. There is an expectation that the worker in the residential setting will be able to manage these behaviours. In addition to the messages in the public discourse, there is a strongly held professional view that residential care is the place of
"last resort.” Research shows that children who come into residential settings may have had an experience of multiple episodes of substitute care (Clough et al., 2006). For example, where foster placements have not succeeded, or have been unable to help the young person, there can be an implicit expectation that the residential placement must succeed. This can lead to an increase in the anxiety of working and living in the setting.

There are two important considerations here. Firstly, how do workers cope with such implicit and explicit messages, and what impact might there be for the worker in the coping strategies that they adopt? Secondly, what are the implications for the line managers of the staff team? Managers within units have the multiple roles of managing the feelings that the work evokes in the staff team, managing the task, and managing relationships with the external managers and outside agencies. The central question for managers is, then, can we manage effectively without addressing and understanding the impact that performing the task has on the staff team? It is this question which is explored here, using a framework adapted from the work of Menzies Lyth
(Menzies-Lyth, 1988).

Defining the primary task
In very simple terms, the primary task is the task that any organisation must perform in order to survive. Where organisations achieve clear task definition, effectiveness within the organisation is enhanced with clear benefits for the satisfaction that staff members derive from performing the task. Where the organisation has a lack of clarity in its task definition, or there are competing and conflicting definitions, there is likely to be increased interpersonal and intergroup conflict.

The reality of working in group care settings needs to be acknowledged here, because caring for children in a residential setting presents significant challenges in task definition. In a residential child care setting the tasks are complex. Indeed there are multiple tasks and not all of these tasks can exist harmoniously. There can also be tensions present in managing and working with the group and working with the individual. There is the potential for conflict in the way that the multiple tasks of the residential care settings are translated into practice. A short outline will be given here to highlight the potential for conflicting ideas and hence an increase in anxiety.

Primary task as therapeutic
One member of staff may believe that his or her primary task is therapeutic. He or she may feel that his or her primary task is to affect change and growth of the young people within her unit. The work is informed by knowledge and understanding of working within the lifespace.

Primary task as custodial
Another member of staff within the same unit may interpret the primary task as being the containment and control of young people who have demonstrated that they cannot succeed in other placements. Such a staff member may believe that the security of the residential setting is essential in containing and limiting the risky behaviours of the young people. He or she may also feel that residential care protects the community.

Primary task as care
A third staff member may believe that the primary task is basic care. Young people within a residential care setting may be given a clear message that they will be given a high degree of physical care such as good nutrition, clean clothes, opportunities for healthy activities and a roof over their head.

An example may be useful here in illustrating how these three functions can influence the decisions that the worker may take.

In the evening, as the group of young people and members of staff are sitting down to dinner, one of the young people begins to throw food across the table. There are three members of staff present. The first member of staff reacts. They give a clear message that the behaviour is unacceptable and indicate that the young person has clearly breached the “rules” for communal eating. They suggest that the young person leaves the table and also outline that there will be sanctions. The second member of staff suggests that they take the meal to the young person's room. The young person needs to eat and this is the third time that this has happened this week. The young person should not be deprived of their meal no matter how unacceptable their behaviour is. The third member of staff agrees that the behaviour is not acceptable, but sees an opportunity to work through the incident with the young person. Rather than banishing the young person, or allowing them to eat alone, there is an opportunity to respond to the young person rather than merely react. In these responses we can see the elements of therapeutic, custodial, and caring definitions of the task. We can also see the potential for conflict (Stevens and Furnivall, 2008, p. 200).

The examples above are, of course, extreme positions used to illustrate the way in which the primary task can be interpreted and perhaps misinterpreted. These different views on the primary task of residential care are reflected in both professional social work literature and in the public discourse. The discussion here should stimulate managers into considering the way in which the task is defined within their setting. Confusion in task definition or conflicting definitions can result in poor morale, high staff turnover, absenteeism and acting out of the confusion by the young people who are being looked after.

Mission statements and statements of purpose
Clearly, managers need to consider carefully the method and means of ensuring that there is agreement within the organisation on the primary task, and of the conflicting tasks that may be present, either overtly or covertly. There are also demands and challenges to be met in the way in which the organisation meets the expectations of key stakeholders. Not only is it expected that all members of staff within the organisation will know and understand the primary task; the
legislative, policy, and regulatory frameworks within Scotland requires extensive collaboration and partnership with all interested parties.

A common means of defining and sharing the task of a residential child care setting is the Mission Statement or Statement of Purpose. It is in these statements that the organisation can begin to address the complexity of the task and explore in a practical manner the means for achieving the task, thereby managing the anxieties generated by the task. Consider the following mission statement of a child care organisation:

Organisation Y believes that children and young people, in the absence of a stable family life, have the right to a secure base for daily life which provides for basic human needs and is conducive to their physical, emotional, and spiritual growth.

While the above statement is relatively uncontroversial, it is unlikely that it will be particularly helpful to the worker grappling with the demands and complexities of working in a residential setting. Where there are such broad definitions the potential for personal and idiosyncratic interpretations of the mission statement are increased. The broad brushstrokes of mission statements need to be supported by clear thinking on how the primary task will be implemented, and what will be achieved by the children and young people. It may be that some of the conflicts of the task are not amenable to SMART objectives. The nature of the work is complicated and not easily contained within quality frameworks. By maintaining an ongoing consideration of the complexity and conflict, managers will be better able to maintain the boundaries of task definition. Clear and explicit task definition externalises the work to be done and helps to prevent
anxiety arising from confusion and conflict.

The commitment and enthusiasm of child care workers and their managers, coupled with the increasing expectations and demands of communities they serve, can result in over-ambitious definitions of the task. The key to effective management is constant monitoring of the “fit” between the objectives of the task and the resources available to meet the task. Where there are gaps between the expectations of the organisation and the resources available to meet the task, the manager can expect decreased satisfaction and increased anxiety within the staff team. The tangible expression of this anxiety is all too evident in the increase of “if “” statements from the staff team, such as:

If we had more staff
If we had more money for activities
If we had more teachers
If we had more time
If we had more training.

Confronting the reality of scarce resources and the recognition that the original ambitious aims of the task may not be achievable is a painful and threatening experience for staff teams. The manager in the care setting must be alive to signs that scarcity of resources is impinging on achieving the primary task.

More importantly, the manager should recognise the importance of confronting reality and helping staff to redefine their expectations. In this way, unintended outcomes of anxiety, such as scapegoating within the team, blaming individual children for being “unmanageable”, or staff burnout, may be avoided.

What happens when the primary task is too difficult?
There is always the possibility that where the task is too complex or overly ambitious, this will create anxiety and the staff team will then redefine the task in order to reduce the anxiety they feel. This process of task redefinition is described as task slipping into anti-task (Menzies Lyth, 1988). What is important here is that the manager understands the unconscious processes involved. The manager in tune with these processes will use the feedback from staff to reflect on the difficulties that the primary task may be presenting. The clues and cues to task slipping into anti-task are similar to the clues for resource issues. The following example highlights shows how the primary task can be subverted. In Anytown unit, there was a high number of new recruits to the staff team. There had also been a period of challenging behaviour which had resulted in damage to the furnishings in the shared recreational area for the young people. The living room was already in a shabby state. Funds were found and the living room was redecorated. The newly decorated living room looked great. All the young people and the staff seemed to enjoy the new levels of comfort. Sadly, one evening a young person spilled their tea on the new carpet. From then on, a decision was made that no young person would be able to take drinks to the living room. All drinks had to be taken in the kitchen. The staff team believed that there would be no more money to replace the furnishings if they were damaged. The primary task of the staff team that evening had been implicitly redefined as “protecting the furniture.” It had, in fact, become anti-task. The reflective manager was able to refocus the staff team and use this experience to explore the feelings they had about not being able to contain the mess. In fact, the mess was not the spilled tea but the spillage of the young people’s emotions and feelings which this inexperienced staff team was finding difficult to contain.

Managing boundaries
The previous sections have highlighted the importance of thinking about the primary task and the barriers which can diminish the effectiveness of the staff team. This section considers in more detail the management functions of maintaining boundaries, both internal and external.

Boundaries are often emphasised as important for young people. Much of the work within units is aimed at helping young people to understand and negotiate boundaries. From an organisational point of view, however, boundaries have a wider meaning which must be understood and negotiated by managers if anxiety is to be kept within reasonable limits. Research such as that by Berridge and Brodie (1998) has consistently demonstrated the importance of the manager in developing a positive unit culture. The management structure within residential settings has the potential for therapeutic or anti-therapeutic effect. If the manager is to provide a positive and enabling role model for the staff team and the young people, he or she needs to be aware of the factors which impact on his or her authority. Such factors must be clear and tangible for both the manager and the staff teams in order to ensure the safety and security of staff and young people in residential care.

A good way to start looking at the management of internal boundaries is to allow time for the team to reflect upon those aspects of organisational structure which may have an impact on the unit. The team should reflect on the nature of the task and how the structure of the unit and the people involved in the unit have an impact on this. This can be envisaged as a triangle:

Once the task has been made explicit, the way in which the structure supports or inhibits this can be explored. Once the team has an understanding of this, the impact of the people in the system can be examined. Although the focus of the discussion may have started off as an examination of internal boundaries, some exploration of external boundaries will inevitably emerge. For example, the role of Care Commission officers in the task will probably be mentioned, or the impact of external managers. By allowing the idea of boundaries to emerge in such a way, the reflective manager should then be in a position to make these explicit with staff and to define limits of responsibility and authority. This in itself is extremely helpful in allowing staff to manage anxiety. Boundaries are often explained as a way of containing or holding. By making external and internal boundaries explicit, managers help to hold and contain the anxiety of staff members, thereby freeing them to carry out their job more effectively.

Conclusion
This paper sought to discuss institutional anxiety in residential child care. It is hoped that some of the ideas in the paper will allow managers to view their work more broadly. It helps to understand that some of the micro-issues have their roots in unconscious, poorly understood feelings of anxiety. If anxiety is acknowledged and managed then the outcomes for both staff and young people in residential care can only be improved.

References

Berridge, D. and Brodie, I. (1998). Children's homes revisited. London: Jessica Kingsley.

Clackson, A., Lindsay, S. and Macquarrie, A. (2007). The homes from hell? Media perceptions of residential child care. Scottish Journal of Residential Child Care, 5, 1. pp. 25-36.

Clough, R., Bullock, R. and Ward, A. (2006). What works in residential child care: A review of research evidence and practical considerations. London: National Children's Bureau.

Gabriel, Y. (1997). Review of the psychodynamics of organisations. Management Learning, 28, 1. pp. 91-105.

Huffington, C., Armstrong, D., Halton, W., Hoyle, L and Pooley, J. (Eds.) (2004). Working below the surface: The emotional life of contemporary organisations. London: Karnac.

Lanyado, M. (1988). United we stand? Stress in residential work with disturbed children, Maladjustment and Therapeutic Education, 7, 3. pp. 23-38.

Menzies Lyth, I. (1988). Containing anxiety in institutions, Selected essays, Volume 1. London: Free Association Books.

Obholzer, A. (1987). Institutional dynamics and resistance to change. Psychoanalytic Psychotherapy, 2, 3. pp. 201-206.

Obholzer, A. and Roberts, V. Z. (Eds.) (1994). The unconscious at work. London: Routledge.

Stevens, I. and Furnival, J. (2008). Therapeutic approaches in residential child care. Chapter in A. Kendrick (Ed.), Residential child care: Prospects and challenges. London: Jessica Kingsley.

Ward, A., Kasinski, K., Pooley, J. and Worthington, A. (Eds). (2003) Therepeutic Communities. London: Jessica Kingsley.

This feature: Macleod, I. (2010). Are you managing? The effective management of anxiety in residential settings. Scottish Journal of Residential Child Care, 9, 1. pp. 43-51.