Touch and Containment in working with children and families who are experiencing difficulties

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 soothing fondling commands eye contact After 5 years 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 ≠Constrainment Term is often (mis)used disparagingly to mean keeping a lid on or warehousing kids.

Holding Environments≠Holding Therapies Holding therapy is a controversial treatment modality. Holding environments is a way of conceptualising the care environment.

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.

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. Emotional Holding

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 Systems of Staff Support Necessary nesting function of containment Containing relationships between staff and young people Staff meetings Supervision Consultancy Other functions of management

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’.

With meeting our own containment needs? So how might we proceed? With meeting the containment needs of our staff? With meeting the containment needs of Children and Their Families?

So how might we proceed? To touch? When, why, how? Or not to touch?

Touch and Containment in working with children and families who are experiencing difficulties