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1-8-11 * The Mulberry Bush School as a Therapeutic Community

 www.childrenwebmag.com/articles/cccf-special/the-mulberry-bush-school-as-a-therapeutic-community

Sunday, June 1st, 2008 by John Diamond

Introduction

Mulberry Bush School

To ‘Love thy neighbour as thyself’ seems a challenging concept at the start of the 21st century. My talk today comes from my experience of working at the Mulberry Bush School, a therapeutic community where we work with severely emotionally troubled children who through their behaviours present themselves, and have often been previously regarded, as loveless and unlovable. Our work is often about nurturing strands or threads of meaning, embracing tiny possibilities of emotional growth towards the child becoming lovable. I have come to recognise that when the prognosis for a child seems full of despair and hopelessness, staying with ‘not knowing’ can keep alive the possibility of a hopeful outcome.

To really stay with ‘not knowing’ or to tolerate uncertainty, is a bit like an act of faith or love - we have to believe in it. Within our work with such disturbed children we face deep mistrust and hatred on a daily basis, and we have to acknowledge and manage this hatred towards ourselves, as well as the hatred stirred up in us towards the child. This requires adults to support each other and engage with the children through a conscious use of self. It is this self knowledge and support, informed by underpinning psychodynamic theory, that helps staff manage the powerful feelings that are projected onto and into them.

Such a discourse about finding love among the ruins of the chaotic and damaged lives of children is only a short distance from the current political discourse about law and order. We hear daily stories about the violence of ‘gang’ culture. We are seldom reminded that the ‘gang’ is a delinquent alternative to family and community, and is created in the absence of these potentially nurturing structures. The ‘moral panics’ and the accumulation of societal anxiety created by these stories invite us not to think, but instead to rush into simplistic and concrete solutions which can demonise children, deepen mistrust and anxiety. These widen the gap between ‘us and them’ creating further social exclusion, and ‘outlawing’ those children and young people most in need of loving care and attention.

From our work at the Mulberry Bush School we know that working with ‘feral’ self reliant and often very streetwise children, requires ‘stern love’. Stern love is about using one’s determined personal authority to manage children in a robust and unambiguous way. A well-intentioned but sentimental view of providing a bit of TLC will not work with our children.

I am reminded of the concept of ‘a labour of love’ invoking the idea of passionate belief in a concept that provides deep personal satisfaction, and allows us to be ‘in love’ with the potential creativity of our workplaces. I will acknowledge some of the literary precedents for this ‘labour of love.’

Some literary precedents

For a number of authors working in the field of childcare and child psychotherapy the concept of ‘love’ has been elevated to the forefront of their most public work. In 1953 Penguin books published John Bowlby’s Childcare and the Growth of Love. This was probably the last and most significant book about child care to reach a lay audience on a mass scale. The book provided a guide to the importance of attachment issues, informed by the growing use of observation from a psychoanalytic perspective. In hindsight, the scale of this publication and its influence seem almost miraculous.

The historical context for this work is significant. After the trauma and social dislocation of World War 2, Britain was immersed in the post war reconstruction period. 1948 saw the birth of the NHS and the Mulberry Bush School. We celebrate our 60th anniversary this year. This was a period of massive collective mobilisation, driven by the need to re-build and stabilise the nation’s infra-structure of social and psychological relationships.

In 1950 in the USA, psychoanalyst Bruno Bettelheim published Love is not Enough, about the treatment of severely emotionally disturbed young people at the Orthogenic School in Chicago. His work was informed by his own experience of the antithesis of love: the institutionalisation of hatred in the Nazi concentration camps. In the title he rises above this experience to maintain a hope that there can be love, and at the same time maintains the critical objectivity to determine that for these most abused and mistrustful of children, the sentimental view that a ‘bit of loving care’ is not enough, as ‘goodwill’ alone will not repair such deep damage. The work of the Orthogenic School is testament to the fact that such a recovery requires great commitment and thoughtful relationship building within a specialist ‘holding environment.’

More recently, in 2004 another now best-selling publication appeared, Sue Gerhardt, a psychoanalytic psychotherapist, wrote Why Love Matters, which explores current research into neuro-science, the effects of trauma on infant brain development, and the importance of attachment. The book provides a continuity of the tradition started by Bowlby and Bettelheim 60 years ago.

Last year I met Keith White, who has been central to the organisation of this conference. Recently, Keith contacted me about the conference, he explained the title and the intended task, and shared with me some of the aspects of his own book The Growth of Love published by Barnabas. In this paper I have used Keith’s concept of the ‘five fingers’; security, boundaries, significance or identity, community and creativity to explore how we might create the conditions for loving relationships for deeply mistrustful children within a therapeutic community setting.

The environmental conditions for loving relationships

Sue Gerhardt’s book Why Love Matters explains how the brain of the human baby physically enlarges as a result of being in a loving relationship, nurtured and stimulated by the mother or primary carer. The flip side of the coin, if the baby experiences ongoing neglect and abuse, is that the evolving brain is flooded and overwhelmed by stress, releasing the ‘corrosive’ stress hormone cortisol. The impact of this flooding of the brain by cortisol and traumatic experience is to ‘freeze’ the growth of the brain.

Although this physiological process was unknown in the 1950s, Barbara Dockar-Drysdale, who founded the Mulberry Bush, wrote her paper The Residential Treatment of Frozen Children in 1958. In this paper she describes experiences and offers clinical vignettes of working closely with the most ‘cold’ and ‘hardened’ of children referred to the school. It is as though she intuitively predicted this concept, as she describes these children as emotionally ‘frozen’ at the ‘point of failure’ of the original attachment relationship.

Dockar-Drysdale regarded these as the most ‘unintegrated’ children. A modern clinical diagnosis would likely be that the child is suffering a disorganised attachment pattern.

The following case study explores aspects of the life experience of such a child who came to the Mulberry Bush School. It highlights the environmental and emotional factors leading to the ‘disorganised attachment’ of the frozen personality and the complexity and dilemmas of developing loving relationships with traumatised children.

Danny’s Story

During Danny’s infancy, because of his mother’s own mental health issues, she found it very difficult to provide the consistent care and nurture that he needed. Danny internalised this experience of absence, and we can imagine that as he grew to be a toddler he began to expect neglect, and conversely he became increasingly self-reliant in order to meet his own needs. By the age of six, without any active parental guidance, he was absenting school, and took to wandering the streets with his sister Pat. During at least one such time they were both abducted and sexually abused. Within the home, his mother was also unable to keep herself safe and regularly found herself in relationships with abusive men. The home environment became regularly violent and unsafe, confirming to Danny that adults could only mediate relationships through chaos and aggression.

One day Danny was in an upstairs bedroom with his baby brother asleep in his cot. Mum and Pat were also asleep. Finding himself on his own again and with his Mum’s cigarette lighter, Danny set fire to some material, which burnt faster than he had expected. He had a glass of lemonade with him and although he tried to extinguish the blaze with it, this was not enough. Mum, Pat and Danny escaped from the house, but the blaze became an inferno, and his baby brother died in the fire.

Today, Danny talks of a terrible feeling of guilt for his actions; he has said that he wishes the lemonade had been in his own words ‘a lot of water’. Because of the absence of mature and caring adults in that place at that time, he is left with this burden of guilt for life.

The inquest on the event found Danny lacking appropriate care and supervision. He was taken into care, placed with foster carers and supported to attend a local school. By now Danny was so traumatised and confused that his behaviour oscillated between being cut off and withdrawn to aggressive attacks on other children. The foster parents and teachers struggled to understand and meet his needs, as they found him to be deeply mistrustful and avoidant of relationships.

Relationships in the family and school became worse and Danny seemed to become more entrenched in his chaotic behaviour. After several foster placements Danny was referred to the Mulberry Bush School for specialist care and treatment. At first he was quiet and compliant. His seventh birthday saw the end of this honeymoon period, he was unable to enjoy his birthday celebration and rubbished the experience for himself. From hereon he became very aggressive to and controlling of the adults around him, and especially disruptive of any nurturing experiences involving food or mealtimes.

His behaviour deteriorated again before the first holiday period away from school, when he became more defiant and his acts of aggression towards adults increased.

In staff team meetings his key-worker commented on how he started to entice other children to misbehave as though to try and get them to enact his hurt and despairing feelings. He also started to copy the chaotic behaviour of other children as a way of communicating his own low self esteem and to dispel his sense of betrayal and anger towards adults. His teacher talked of his reluctance to talk about feelings, and how this led to outbursts of violence with no apparent trigger or motive.

In a recent consultation meeting with our consultant psychotherapist the staff team talked about their feelings of despair and deep sadness that they carried for Danny in their day to day contact with him. His key worker commented that like parents the staff involved felt the overwhelming desire to want to take the pain and guilt away from him. The painful realisation for the team - their ‘experiential learning’ - is that there is no magic wand to wave, and they will need ongoing support to manage these feelings. In this sense an important foundation of our work is to offer stability of placement, continuity of concern and understanding, and to carry hope for the child through those times when they are in touch with their most desperate feelings.

We hope to offer Danny three consistent years alongside mature and caring adults. Danny still has a lot to learn about how to get on with people and to be able to learn in the classroom situation. He has started to respond to praise. We hope that as his personality strengthens and his self esteem grows he will, little by little, be able to leave the pain and chaos of the past behind for a more productive future.

Keith’s ‘five fingers’; the conditions for love and growth

In The Growth of Love Keith White has identified five ‘fingers’ to support the conditions for love: security, boundaries, significance or identity, community, and creativity. I am reminded of the similarities with what we call the five characteristics of the therapeutic community concept: attachment, containment, communication, participation or citizenship, and agency. I will use the ‘five fingers’ to explore the case of Danny.

Security

The first stage of our work, after a thorough assessment process, was to offer him the security and containment of the Mulberry Bush School through admission. At this stage when the child has little sense of agency (meaning ‘to be an agent of one’s own actions’) we would not expect Danny to have a concept of safety or security, never mind to expect or want it. This is the work of the adults who work closely with Danny on a day to day basis. They are involved like hyper-vigilant parents in the minutiae of daily routines and preoccupations that over time become the containing framework for the child.

Boundaries

Danny would immediately be faced with boundaries, starting with the external norms or rules of the household and classrooms, and then ‘inwards’ to the inter-personal boundary-setting which ultimately helps the child distinguish right from wrong, links actions and consequences, and creates the necessary separation between ‘you’ as the adult and ‘me’ as the child - boundaries, which like our skin, eventually define our separateness from the external world.

These inter-personal boundaries have to be fought for, negotiated, explained and then re-set in the same way five hundred times a day. Boundary-setting around relationships and acceptable behaviour requires duality: it is an act of love supported by focussed and constructive use of aggression. This same ‘battle’ is played out daily by mothers with toddlers in every supermarket in the land. We never expect a child to love us for saying no. The imposition of boundaries is in itself an act of love and positive regard for the child. Winnicott wrote, “Love means caring for the other as the mother cared for the infant”.

Significance or identity

These are at the core of our therapeutic task. One’s significance and identity are developed out of a sense of having ‘good enough’ parenting, the secure base from which we can develop self-affirmation. We can then have a sense of who we are. But for children such as Danny, a sense of self is very often an alien and frightening concept. As children in our care start to mature emotionally and their personalities become more integrated, they enter a more ‘depressive’ position. The bundle of impulses and feelings which once drove them becomes connected up to a sense of agency. When we face the magnitude of Danny’s realisation, in which he is able to acknowledge that he wished the lemonade ‘had been a lot of water’, then we can also understand the adults’ empathic desire to want to take those most painful of feelings away from him, because he and they are literally having to bear the unbearable.

Community

Keith identifies community as the ‘fourth finger’. The Mulberry Bush is a therapeutic community. The therapeutic community movement has its own history which include monastic and Quaker influences, which make it a rich and valuable tradition of primarily offering sanctuary. Chris Beedell used the following mediaeval French medical dictum to describe the work of the therapeutic community, “To comfort - always; to relieve - often; and to cure - sometimes.”

The modern therapeutic community grew out of the Northfield experiment administered by Wilfred Bion, Tom Main, Harold Bridger, and S.H. Foulkes to re-engage soldiers with the enemy, when they had been fragmented by the experience of shell shock (now Post Traumatic Stress Disorder). These psychiatrists of the time turned the concept of the war effort on its head, by organising the soldiers to use their group experiences to engage with their own personal enemy of mental and emotional illness. This experiment gave rise to the concept of ‘community as doctor’ or ‘social psychiatry’.

The therapeutic community as a place of healing implies a place of sanctuary. Winnicott talked about the role of the evacuation hostels working with highly disturbed children in World War 2 as places to ‘cover’ the pain of ‘naked souls.’

The community offers sanctuary as it can tolerate and contain high levels of disturbance and emotional pain, and offer reflection and understanding to the children placed in it.

For children such as Danny I believe the concept of community offers a multitude of meanings and layers, which over time will be internalised and construed by the child as therapeutic or salugenic, meaning ‘wholeness inducing’. Our model of education and group living is role-modelled by mature adults. Children live in a group, but more importantly live as a group. They play and do their school work among and between different groups.

This combined patterning of the community creates and builds a day to day experience of ‘the other’ which requires children to challenge their self reliant and mistrustful view of the world, and start thinking about the ‘social and emotional’ through co-operation and understanding other individual and group needs. A therapeutic community is containing for children because every interaction can be observed, managed and talked about. Such a ‘sense of purpose’ is built into the everyday routines and activities.

The therapeutic effect of community living is multi-dimensional. For the first time in their life a child can suddenly see that another child has similar or even greater difficulties than himself. Or that another child who one year ago seemed to be ‘impossible to manage’ is now talking lovingly about his key worker or teacher. Internalising such experiences over time helps children to feel that they are no longer alone and marginalised in an apparently hostile world. The primary task of making meaning through caring justifies the ongoing existence of the community. The therapeutic community is the antithesis of the concentration camp; it attempts to transform hate into love, and its organisation and energy for change is in itself a labour of love. There is an African saying that captures this dynamic, ‘It takes a whole village to raise a child’

Creativity

And on my tour of the dynamic conditions for supporting the growth of love, I come to the fifth and final of Keith’s ‘five fingers’, creativity. I have tried to define the concept of love in therapeutic child care through the need to acknowledge and own our innate and potential hatred and aggression. The concept of creativity also stems from the dynamic interplay between creation and destruction, light and dark, love and hate. The painter might paint over or destroy a canvas if the emerging image is not right. The potter will crush the lump of clay back into a formless mass if the image of the vase in her mind does not become realised. The mother might hate her child for behaving so badly on the shopping trip, but she will not give up on loving him.

At a recent training session in Dublin with a group of care workers who work with emotionally troubled children and young people, I used the following quote from Buddhism to capture this dynamic tension between creativity and chaos, “Chaos is inherent in all compounded things - strive on with diligence.”

It asks us to accept that within the creative there is also chaos, and in their work with emotionally troubled children and young people, before the eventual acknowledgement of love, they would have to encounter and accept pain and hatred. We are invited to remain accepting of this inherent tension, the volatile state of things, and to ‘strive on’ with diligence, strength and thoughtfulness.

Managing anxiety to find love and other four letter words

In 1952 the Christian theologian and philosopher Paul Tillich wrote his book The Courage to Be. After being deprived of his professorship in theology by the Nazis, Tillich left Germany in 1933 to work in the USA where he eventually taught at Harvard and the University of Chicago.

In The Courage to Be, Tillich identifies two forms of anxiety as inherent to the human condition: pathological anxiety and existential anxiety. According to Tillich, pathological anxiety is the inability to cope with life, and requires the creation of psychological defences to protect the individual from their struggle with day to day life. Existential anxiety, according to Tillich, is driven by the three ‘big issues’:

1 the anxiety of fate and death;

2 the anxiety of emptiness and meaninglessness;

3 the anxiety of guilt and condemnation.

I relate this to you because I believe that the concept of ‘the management of anxiety’ in order to establish love is central to the work of both the mother and the task of residential therapeutic child care. At the training session in Ireland I also decided to use Tillich’s schema as a frame of reference for thinking about our work with very troubled children. The adult care workers at the training agreed that the children they worked with suffered very obvious pathological anxieties, driven by their chaotic, confusing and often abusive formative experiences. But they were also able to acknowledge their losses and separations, their own lesser but nonetheless pathological anxieties.

I invited them to think about Tillich’s more ‘adult’ existential anxieties and whether these had meaning and relevance within their work. They felt that the anxiety of fate and death did have significance: these children - through no fault of their own - had been handed or dealt a fate of managing the psychological ‘death’ of their initial attachment. They felt that without the help of a planned therapeutic intervention this experience becomes a ‘living death’, because the psychological consequences on the developing personality are so deep and the impact so confusing.

They identified the anxiety of ‘emptiness and meaninglessness’ as how children and young peoples often described their own lives, where the emptiness and absence of relationships and a loving family was a daily reality. They discussed how meaning in their lives had been ‘disabled’ by their disconnection from feeling states, and by the absence of loving adults to create meaning with and for them.

Guilt and condemnation were also identified as anxieties which were very much alive for the young people they worked with, for example the guilt of the child thinking, “It is my fault” or “It is because I am bad” that no-one wanted me. They also identified the condemnation of being the child in care, the child who was not wanted and did not experience the loving and caring family, and felt marginalisation from mainstream social life as a result of this experience.

The staff talked about the dilemmas of working ‘close in’ with the children, the violence, despair and rejection they managed, but they knew that they would ‘keep coming back’ to provide the stability and continuity that the young people needed but had rarely experienced before. It seems that within residential child care the management of hateful and hurt feelings must be accepted as an integral part of the construction of loving relationships.

Conclusion

So what does this tell us? At least that managing personal anxiety is part of the human condition. These anxieties bind you and me and the 62, 000 children in the UK care system. And the anti-dote ? Sadly, there is no miracle cure for anxiety. We will continue to be subjected to many four letter words, but we hope to maintain the courage and maturity to continue to offer and role-model caring and nurturing relationships which grow out of that other four letter word ‘love’. As well as tolerating uncertainty and staying with not knowing, we do know that feeling loved, feeling wanted, and belonging to a group or community that cares about you, is the only way for children to grow emotionally and to become adult, and to hopefully be able to aspire, in Tillich’s words to, ” reach self-affirmation, to attain the courage to be.”

Bibliography

Beedell, C. (1992) Poor Starts, Lost Opportunities, Hopeful Outcomes, Charterhouse Group

Bettelheim, B. (1950) Love is not Enough, New York, Free Press

Bowlby, J. (1953) Child Care and the Growth of Love, Harmondsworth, Penguin

Gerhardt, S. (2004) Why Love Matters, London, Routledge

White, K. (2007) The Growth of Love, London, Barnabas

Winnicott, D.W. (1984) Residential management as treatment for difficult children. In Deprivation and Delinquency, London, Tavistock

Tillich, P. (1952) The Courage to Be, Yale University Press

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