It was a day that promised, in the words of Leslie Ironside, Director of the Centre for Emotional Development, ‘plenty of manure for your garden’. The less green fingered among us, or indeed those more ambivalent about life story work should, nonetheless, bear in mind Adam Phillips’s Winnicottian caution: ‘You never know what the unconscious will make use of.’ For me it was the rolls of decorator’s lining paper used by Richard Rose in his life story work with children. These came to mind unexpectedly in a recent session with one of my more disorganized and fragmented patients. Thrown into disarray each time he ‘rediscovered’ the scraps of drawings in his folder, he now draws avidly and communicatively on his newly supplied lining paper, unrolling and rolling away his previous creations.

Rose, pioneer of life story work with looked after children and self-confessed mental magpie, would have been pleased. ‘If by the end of the day you’ve picked up just one idea,’ he told us, ‘and you go away thinking, “I like that idea; I’m going to take it and use it,” I’ll feel I’ve done my job.’ Indeed, this one-day training led by Rose and held in June at the Centre for Emotional Development in Brighton, was an object lesson in object use, a full-on experiential learning process packed with activities and ideas, from the lining rolls, through techniques for information gathering (did you know that anyone can apply for a copy of anyone else’s birth certificate, or that a birth certificate is not proof of identity?), and information sifting, to the use of two glasses of plain and coloured water to demonstrate the emotional exchanges between developing child and mother, and the ‘internal working model’ that can evolve from this. This last idea, Rose himself admitted he had ‘nicked’. He has found it enormously helpful in conveying to foster carers something of a child’s early experience, especially once he places his hand over the top, to show how a child may close up emotionally: foster carer tries to pour in ‘love’ but there’s no opening, everything spills ‘the carer is left with a mess on her hands and the child sees nothing going in’. Leslie Ironside likened the two glasses demonstration to Winnicott’s use of the spatula in his ‘set situation’ – it captures the attention of those involved and, if, having made it your own you feel it has value, you can go on using it again and again. ‘It’s a question of having confidence in your tools.’

Of course, to the skeptical child psychotherapist, life story work itself can seem a dubious tool; in the wrong hands, yet another formulaic technique aimed at waving a magic wand over the problems of disturbed and damaged children. In contrast to the rich and complex ‘Bayeux tapestry’ that Rose brings to life with his rolls of lining paper, many of us who work in Looked After Children teams, or in residential settings will have come across the airbrushed versions of children’s histories that can pass for their ‘life story book’; the ‘tick-bock exercise’ one social worker at the study day described, that follows a child from placement to placement then sits languishing at the back of a cupboard. Perhaps this is what deterred other child psychotherapists from attending the Brighton study day. Of the 17 participants I was the only child psychotherapist (or, rather, ACP member, as Leslie Ironside corrected me; the title, it seems, is becoming increasingly widely used), among a collection of social workers, school counsellors, art therapists, midwives, health visitors and foster carers, all willing to dedicate seven hours on a bright if chilly Saturday to finding out more about this work. For, as Diana Cant, long-time consultant child and adolescent psychotherapist at Greenfields therapeutic community in Kent has argued so cogently, at its best life story work can give back to a child ‘the details of his life and history’, offering the possibility of exerting some control over his or her life ‘rather than feeling at its mercy’.[1]

Cant describes integrating life story work into her psychotherapy sessions with an adolescent patient. More often, we may find ourselves working alongside social workers or care staff involved in life story work, a collaboration that when it works well can offer a fruitful exchange of insights about the child’s experience, a joining together of inner and external world. I was prompted to attend the Life Story Work study day when a little boy I work with asked, ‘What’s a granddad?’ Prior to this I had had meetings with another patient’s keyworker and the residential liaison officer, trying to infuse some vitality and truth into the rather saccharine and ultimately misleading life-story book that her well-meaning social worker had produced. ‘I hate my name,’ this little girl had told me. ‘It doesn’t feel like my name.’ What might it mean to feel no connection with your name, or to lack any concept of a grandfather? And how might the experience of life story work help?

Richard Rose has a long history of addressing such questions. He is currently a deputy director of SACCS and the Mary Walsh Institute, a UK institution providing specialized therapeutic treatment based in residential and foster care settings for children severely traumatized by abuse and neglect. Before he joined SACCS 14 years ago, he had worked in child protection, coming to child and family social work from a background as a residential care worker. He now does life story work with children and their carers in the community and has a caseload encompassing children in Wales, Scotland and Northern Ireland as well as England. Two days before our workshop, he had arrived back from consultation and teaching work in Australia; he has recently been called on to work in Portugal. If the imagination and generosity with which Rose approached the study day are anything to go by, it’s not hard to envisage how well he might engage with any audience, and, more importantly, with a child in their life story work, as he attempts to discover, ‘Who is this young person, how does she feel, how does she think?’ Rose is a man who can breathe life into any story – not least the story of Abigail and her dubious lover Sinbad, a tale he used to illustrate how easy it is to elicit value judgments, how hard it can be to resist the quest for a simple, one-sided, black and white narrative, for adults as much as children.

Simply stated, for Rose the point of life story work is, ‘to establish an holistic understanding of children and their need for understanding their identity’. But Rose wanted us to explore the implications of this for ourselves. We were divided into groups (‘Right, who’s going to be your leader?’ – traditional lesson in power dynamics and their impact on feelings about sharing thoughts and ideas). Between us, we then had to generate one ‘eco plan’ detailing the pros of life story work (our group included creating a coherent narrative, integrating a sense of self, opening up the possibility of sorting past, present and future, the experience of learning about oneself through another…) and one detailing the cons (eg, the possibility of re-evoking recent trauma, or of creating an illusion of coherence and closure). The point, though, about this exercise was to contrast adult preoccupations with a child’s worries about life story work – ‘Do people really care what I think?’ ‘You won’t like me when you find out what I’ve done.’ ‘Will my family be told?’ ‘What if I find out I’m bad?’

From there we moved on to the process of information gathering, of creating a meaningful ‘information bank’. First though, in our small groups, we had to wade through a case study collated from all those sheaves of paper that can go to make up a child’s file, the catalogue of events, reports and assessments that appear to tell a story, but more often overwhelm and obscure. We were asked to take it in turns to read this out, so that we could experience the full mind-numbing impact, despite our best attempts to elicit facts or imaginatively engage with the child’s experience.

Rose appears to have perfected an approach to ‘opening up’ a file that extracts maximum information. He takes a single fact at a time, lists it in a box, then lists the next in chronological sequence, and so on. He then compiles all the questions prompted by these facts or the links between them (eg Mum has car crash, sent to hospital – is there an accident report? Who else was in the car? Was this the reason for the child’s early birth? And so on). These questions are guided by three principles: What is necessary to know? What is safe to share? What would the child want to know? Rose claims he can end up with 8,000 questions. That’s a lot of research work, and perhaps highlights how little ‘truth’ can be held in the fattest of files. It also explains how Rose knows that anyone can apply for a copy of anyone else’s birth certificate and that if you don’t want to appear in 192.com, you have to ensure your details are removed annually, as well as the fact that maternity wards are particularly responsive to requests for information, and will often provide the child’s original name tag as well as identify the midwife present at his or her birth. This information gathering, Rose maintains, ‘is the most important part of the whole process’. Indeed, it is the process rather than the product, Rose stressed, that is key to life story work.

There were plenty more excercises for us to process, including an interlude in which each group had to pick an organising theme and then illustrate feelings in terms of this theme. Our group chose ‘sea’. Now, try to imagine how you might portray silly, confused, happy, sexy, frustrated in this way. (In passing, I should mention, that our group won the ‘most interesting theme’ award from Richard Rose; well deserved, I thought, though probably down to the presence of an art therapist among us. However, Leslie Ironside, who was also in our group, rather disloyally – or diplomatically, depending on your interpretation – nominated the group who chose ‘food’ for their theme. And, lest anyone should feel hard done by, another group were commended on their ‘beautiful shoe’.)

These excercises can take it out of you, and it is worth noting, in relation to the children and carers he sees, that Rose works in one-hour sessions every fortnight – that is as much, he feels, as they can manage. So, perhaps taking pity on us, Rose took the floor for most of the latter part of the day, allowing us to sit in quiet attention for a while as he spoke about his work and showed some remarkable examples of the ‘books’ that children have created with him and their carers. Recently, Rose explained, he has tended to be called in to do life story work at a point when a foster placement is about to break down. So far, none of these placements has subsequently broken down; not a bad success rate and a result he attributes in part to the fact that he always works with the primary carer and child together, offering the containment for thoughts and worries to be opened up in a way that strengthens bonds. This suggests an immediate tension between life story work in Rose’s model and the work of a child psychotherapist – at least as it is widely perceived. It is telling that SACCS employ play therapists rather than child psychotherapists and the mantra of ‘no more secrets’ overrides questions of confidentiality.

Differences aside, there remains a healthy exchange to be had between child psychotherapists and those involved in life-story work. After all, you don’t get to do the sort of work Rose does without being a good listener. While, I confess, it was something of a relief after such an action-packed and technique-driven presentation to return to the simplicity of the child psychotherapist’s tools – the child’s box and oneself (albeit with my rolls of lining paper), it was disappointing to be the only child psychotherapist present on the day. As Diana Cant illustrated, there is room for some creative thinking on our part, particularly given that a willingness to confront uncomfortable truths is intrinsic to our work. ‘Whatever the past was, the child lived through it and survived,’ Rose told us in conclusion, quoting Vera Fahlberg, ’and so can live with the truth.’[2]

[1] ‘The Birthday Boys’ Journal of Child Psychotherapy, Vol 34, No2, August 2008, p212

[2] Helping Children When They Must Move, 1981, p51

This important and timely conference, organised by Leslie Ironside, Consultant Child and Adolescent Psychotherapist and Director of the Centre for Emotional Development, addressed some of the difficulties raised in trying to understand the complex pattern of emotional and developmental difficulties children who have been in care present.  Ensuring that they receive the right kind of help and support depends on how we recognise and interpret these difficulties.  Perhaps the context of this discussion is set by the significantly raised levels of mental ill health in children who have been in care as compared to children in private households.  72% are rated as having a diagnosable psychiatric disorder.  But does a psychiatric diagnosis make sense of the range of difficulties Looked After and adopted children may present with?

Instead, have you used categories such as “developmental” or “complex” trauma, or “attachment difficulties”?  Do you have a worry that Looked After children may be diagnosed with ADHD and prescribed medication when past histories of neglect and abuse have not been taken into account?  Why do many Looked After children have autistic traits, oe “quasi-autism”, and how helpful is this kind of description?  Why do so many children who have been in care have a diagnosis of Conduct Disorder, and form such a high proportion of the criminal justice system?

This conference explored some of these questions, and others.  Perhaps you may wonder whether we really need to assess and diagnose Looked After children using a psychiatric framework?  I think the importance of careful assessment and diagnosis is to ensure that these multiply deprived children and young people receive appropriate therapeutic support.  One theme focussed on by all the speakers concerned the kinds of deficits children who have experienced early neglect and abuse may have.  In addition to emotional and relationship difficulties, they experience very high rates of neurodevelopmental difficulties, and speech and language disorders.  Speakers discussed the impact of genetic inheritance and environment and how these factors interact to create a complex pattern of emotional and neurodevelopmental difficulties.

Gillian Baird, Consultant Developmental Paediatrician at Guy’s and St Thomas Trust,  spoke about the different impact neglect and individual episodes of abuse may have on development.  She discussed Michael Rutter’s studies of Romanian orphans brought up in institutions with little care-giver contact.  Although these children were later adopted into good homes, and there were significant improvements in speech and language, in adolescence they displayed challenging behaviours.  She argued that early neglect has significant effects on brain development, leading to difficulties for example with executive brain function.  She described characteristic difficulties with thinking through experiences and with emotional regulation and impulsivity.  By contrast, she argued, individual episodes of abuse have a less damaging impact on the brain.

Gillian Baird also talked about the fact that Looked After children often appear to have autistic characteristics, but fail to qualify for a diagnosis of autism.  She argued, and the audience agreed, that the description “quasi- autism”  is not a very helpful one.  The DSM-V, which is currently in process of being drawn up, will have a new diagnosis of disinhibited social engagement which may be useful.  It will link difficulties in social interaction with early failures in care giving, neglect and abuse. 

Other speakers described alternative ways of understanding the mental health difficulties of Looked After children.  Margaret de Jong, Consultant Child and Adolescent Psychiatrist, discussed the idea of trauma as at the core of these children’s mental health difficulties.  She is Head of the Parenting and Child Service, an assessment and therapuetic service for children with a background of abuse, neglect and trauma, based at Great Ormond Street.  She discussed the fact that many Looked After children have experienced chronic trauma, which impacts on their emotional and cognitive development.  Some people use the term complex or developmental trauma as a kind of short hand.  Unfortunately there are various problems with using this as a formal psychiatric diagnosis and it has been rejected as a diagnostic category in  the new DSM-V.  She also talked about the difficulties of using the diagnosis Reactive Attachment Disorder, which in the DSM-V will be used only in relation to very young children’s attachment styles.

Paul Holmes, Consultant Child and Adolescent Psychiatrist, and founder of the Attachment Project, an inter-agency service for Looked After and adopted children based in Brighton, discussed attachment as a model for understanding these children’s difficulties.  He drew largely on the work of Patricia Crittenden, and also on Peter Fonagy‘s work on the importance of secure attachment for a capacity to understand one‘s own and other people‘s feelings, and to be able to regulate one‘s own emotions.  Attachment is both an aspect of relationships in the external world, but also shapes internalised models of self and relationships.  A child who does not have a secure attachment is unable to develop a sense of trust and know who they are.  He described how we all re-enact these internalised patterns, or internal dramas, in life and in therapy.  Crittenden rejects the concept of disorganised attachment, and instead conceptualises all attachment behaviour as a survival strategy, however contradictory it may appear.   Looked After children, Paul Holmes argued, lack an integrated sense of self, and use different attachment strategies depending on the situation.  This would explain, he suggested, why some Looked After children behave differently at home and at school.  Finally he argued that attachment styles can be influenced by different kinds of relationships or by psychotherapy, which offer a different attachment experience.  I would add that Fonagy and Anthony Bateman have developed a specific kind of therapy - Mentalisation Based Therapy - which aims to develop a greater capacity to understand what is going on in one’s own mind and in other people’s minds for people diagnosed with a borderline personality disorder.  They think that BPD often derives from highly dysfunctional parenting associated with neglect and abuse in which the infant is not able to have an experience of attachment and is therefore unable to develop consistent protective internalized models of self and relationships.  

Finally Julie Withecomb, Forensic Child and Adolescent Psychiatrist,  talked about the high numbers of people in the criminal justice system who were Looked After children.  23% of the prison population and 30% of children in custody have been in care.  By age sixteen, one third of Looked After children have been in custody, and two thirds have a conviction by their early twenties.  The more a child is moved in care, the greater the risk of offending behaviour.  She described research which shows that abuse and maltreatment in early childhood causes changes in the neurotransmitters in the brain.  These changes in turn affect the response of the amygdala to stimuli, which affects the understanding of emotions and capacity to regulate them.   These young people need careful assessment and a range of targeted interventions to help them develop the capacity for emotional regulation, executive brain function and social skills.

The overwhelming theme that emerged as a result of this conference was how important it is to ensure that Looked After children and young people are offered detailed multidisciplinary assessment and a package of interventions designed to support them with their various deficits.  For example, they might need Speech and Languge support, a cognitive assessment to assess global or specific Learning Disability, support focussed on difficulties with concentration and impulsivity, as well as therapy to help them with emotional and trauma related anxieties and difficulties with managing their own feelings and forming more rewarding relationships.  In addition, their carers or adoptive parents need support to help them understand and manage the emotional and behavioural difficulties these children may present.  It reinforced the need in all the audiences’ minds for dedicated resources to provide the high level of assessment and intervention these children need. 

Dr Anna Cohen                                                          8^th July 2011

Child and Adolescent Psychotherapist

Brighton and Hove CAMHS

Sussex Partnership NHS Trust

The number of teenage pregnancies in the UK is the highest in Europe. Terminations are also high and those who have their babies often are involved with Social Services. This fifth annual conference on the early years of life, staged and organized by the Centre for Emotional Development in Brighton, was as, “ a study day…looking at what it means to be a teenage mother or young father and how best to understand and be of help as a professional person working within this field.” The day attracted a wide range of practitioners working with young parents and children. Dr Leslie Ironside, not only chaired the discussions, but also provided acute observations in response to the speakers. The actively participating audience widened and deepened understanding of the issues as the day progressed.

Kate Billingham, Project Director of the Family Nurse Partnership (FNP) Programme opened the day with an upbeat overview of a service that aims to reach ‘difficult to reach’ young mothers and fathers. Agencies offering such work frequently describe clients with whom they have attempted work, as ‘failing to engage’. It is usual policy for helping agencies to place responsibility for the client’s engagement with the client, whose reluctance is often seen as due to a want of ‘motivation’. The FNP are turning this view on its head by placing the responsibility for engaging the client with their service, with themselves, via the nurse practitioner. The nurse continues to visit, even though the client’s response is negative or defensive. If the nurse is able to prove that s/he is committed, then the client will likely be won over, enabling work to begin. 

The FNP originating in the United States and now fast achieving government recognition and backing in the UK, offers an intensive prevention programme for young parents which runs from pregnancy until the child is age two years. Ms Billingham said that they can benefit children and families who usually have the poorest outcomes; improve antenatal health, child health and development and parents’ economic self-sufficiency. The nurse practitioner visits a family and conducts ‘structured conversations’ and also activities to improve self-efficacy, change behaviour and build attachment. The object then is to lead the parents to developing a new story of themselves and a new understanding of their lives. This will provide improving relationships with their infant, the other parent and their wider family, whilst also helping them to access wider services. Kate Billingham said that the FNP has had consistently good results and outcomes across three scientific trials in the United States. The audience was impressed and interested, especially since many had come from work settings where, although to reaching out to clients, none had encountered a ‘We are responsible for the client’s engagement’ approach before.            

Margot Waddell then read her paper entitled, ‘Why Teenagers Have Babies’. Although Dr Waddell placed much emphasis on her ‘key’ concepts of containment, the Oedipal configuration and the ability of a developing young child to tolerate the inclusion of a third party, the audience in the discussion made little reference to them. This was likely because only a minority of the audience felt at home or sufficiently familiar with these ideas. Also, having just had a Power Point presentation, the participants were perhaps not ready to attend to a closely argued paper.

Dr Waddell’s paper was, however, very rich in ideas and detailed examples from counselling with teenage mothers. She showed from a psycho-analytic view what might miscarry, or be missing internally, when speaking, as Kate Billingham did, of young parents having had little experience of being effectively parented themselves. Dr Waddell described failures in emotional containment, non resolution of Oedipal conflicts, and there being no available means in the family for the infant or growing child to overcome and then to tolerate the presence of a third party. She said that whilst these unresolved issues and conflicts might remain dormant during a child’s ‘latency’ period, they can break out afresh and often dramatically, in adolescence and take on further poignancy when the adolescent becomes a parent.

Professor Joan Raphael-Leff provided the material for the third presentation, entitled, ‘Adolescence as a Second Chance’. This presentation was aimed at providing training and insight for practitioners working with pregnant teens and very young parents. Unfortunately, Professor Raphael-Leff was unable to attend, and Dr Ironside presented her material. Like Kate Billingham, she also emphasized that teenage clients are notoriously difficult to engage, but argued that it could be achieved through emotional understanding, validating the young parent’s importance, naming conflicts and helping the parent become curious about their own and their baby’s feelings. Professor Raphael-Leff stressed that the adolescent mother has to cope with negotiating herself through her adolescence, as well as negotiating the new experience of and learning about becoming a parent. She included material aimed at treating maternal disturbance, particularly depression and persecutory anxiety, which has implications for the unborn child. She said that availability of fathers is important, not only to the child, but also to the young mother. In addition, children who have lived in poverty and deprivation, with attendant school problems and delinquency, are more likely to become teenage parents.

            Early on in the day, the conference established that teenagers over 16 who have completed their secondary education present few problems when they have babies. Of course, young motherhood is not new and not abnormal, but problems arise when young parents are socially disadvantaged, under educated, emotionally immature, and come from dysfunctional families. Being raised in such circumstances usually means that the young parents have had little experience themselves of being effectively parented and cared for.

Dr Ironside then showed Wasp, a short film, made by Andrea Arnold in 2002. It highlighted in dramatic vignette form, the difficulties of a young single mother, desperate to have some life and excitement, coping alone with three young children. When she is out with her children near to her flat, a young man turns up that she used to know. She denies that the children are hers and agrees to meet him later in the pub. She leaves the children outside in the pub car-park and as darkness falls, the kids scavenge around for food. Then youngest child is nearly stung in the mouth by a wasp. The film makes the important point that teenage single mothers, and fathers, need support so that they can participate in teenage life.           

            The final presentation on ‘Young Fathers’ was given by Adrienne Burgess of The Fatherhood Institute, She offered statistics concerning this often elusive client group, including that 25 percent of young dads are under 20 and that they are generally more disadvantaged than young men in the wider population. Importantly, Ms Burgess stressed that when young fathers express disinterest in their children, it is mainly associated with financial insecurity or confusion and anxiety about how to take care of babies or children. Nevertheless, most want very much to stay connected to their children.

Ms Burgess said that research in 2002 found that young fathers were often ignored, marginalised or made uncomfortable by professionals. A later study showed that they appear to be perceived as having a poor parenting capacity, by professional who know very little about them. In other words, they are often targets of professional prejudice. In the Family Courts, the interest group Fathers for Justice, make a similar point.  

She said that the young mother’s perception of support from her baby’s father is linked to a good birth experience and a more positive adjustment to motherhood. When involvement with the father decreases, a teenage mother’s parenting stress increases. However, involvement of fathers has a good effect on children that include fewer behaviour problems in the child, both early in life and at school. She stressed that it is vital is for professionals to assess a young father and not to ignore him. Also fathers, often as much or more than young mothers, are much in need of clear and accurate information. Not having good information leaves fathers alone with their fearful assumptions and feelings of embarrassment or exclusion.

The Fatherhood Institute collates and publishes research on fathers, helps shape national and local policies, lobbies for changes in law and is a provider of training and publications on ‘father-inclusive’ rather than ‘father-blind’ practice. Ms Burgess’s presentation gave rise to much lively discussion and impassioned contributions (mostly from men) from the audience.

So why do teenagers have babies? Some to fill emptiness, some in the hope of guaranteeing unconditional love from their offspring, some to stop feeling like a baby themselves, some in rivalry with their still young (and still sexually active) mothers? All of these, but I noticed, that no-one, at least no one I remember, spoke of marriage, which for pregnant women provides security and support for the mother’s dependent needs. In response to Margot Waddell’s paper there was discussion about the centrality to the teenage mother of her mother, on whom she will seek to depend. What was less noticed though was how often nowadays teenagers look neither to the family, nor to their partners (much less spouses), but to the welfare state to provide a dwelling and an income. Recently on BBC radio, a panellist on the ‘Any Questions’ team commented, “As a society, we are abolishing marriage and substituting the welfare state.” In my work for the Family Courts, where I see families and children, the teenager looking to gain a home and benefits upon the birth of the baby has been common enough to be the norm. This has suggested to me that another reason why teenagers have babies is to provide them with a role and also a route to independent living that they might not otherwise have.

John Lawrence  

Psycho-analyst.

This day conference was organised by the Centre for Emotional Development in Brighton.  It was the third annual conference focusing on some of the challenges that we face in fostering and adoption. 

The day comprised of four speakers, with each talk followed by small group discussions and feedback to the large group.  This worked very well and enabled each participant to contribute to the day.  Dr. Leslie Ironside, Consultant Child and Adolescent Psychotherapist and Director CfED, spoke first on ‘Keeping Multiple Families in Mind.’   He evoked feelings of empathy in the audience as we heard a child’s perspective on being fostered and thought about Fairbairn’s quotation on the greatest need of a child being to feel genuinely loved by his parents and to know that his parents accept his love, and the frustration of this desire being the greatest trauma a child can experience (1952).  Leslie then introduced us to the ‘dilemmatic space,’ an organisational consultancy term, where there is no obvious right thing to do and there are conflicting pulls, creating a lot of anxiety.  This set the scene for the day, as we considered children who have to keep multiple families in mind. 

Leslie gave us three case examples of such children and families.  Through the relating of his work with a teenage mother with three children who had been adopted, Leslie described how hard the mother tries to stay in Klein’s depressive position, to keep thinking and to stay in touch with difficult feelings.  She is ‘raising three children in her mind,’ which was an interesting and moving perspective on keeping multiple families in mind.  We considered how easily systems around children and families fall into paranoid/schizoid positions as they receive strong projections from them.  Leslie emphasised the importance and the challenge of us as workers with complex families maintaining the ability to think, to make decisions and to help children and families to develop internal resources. 

The groups all discussed similar themes: the need for reflective space in our work; the need to thoughtfully support contact with birth parents; a concern about the amount of conflict that children hold in their minds with their multiple families; a need to respect the views of members of each family system.

The second speaker was Lorne Loxterkamp, Consultant Child and Adolescent Psychotherapist.  He spoke on ‘Understanding Contact with Birth Parents: Truth and Meaning.’  We were challenged by Lorne to question the current thinking about contact with birth parents.  He pointed out that apparently good contact could be harmful.  Further, there is no evidence that lack of contact has inevitable negative consequences or that its presence brings benefits (see CfED website for source).  The many arguments that have been made for contact with birth family were questioned closely and alternative arguments were made, which seemed to have as their central motive the concepts of truth and meaning for children.

Lorne argued that the ‘conviction that healthy identity and self-esteem depend on the child having a positive view of birth parents guilty of maltreatment’ leads inevitably to the child thinking that if he is meant to feel positively about these birth parents, then it must in some way be his fault that he was removed from them.  Finally, we were left with the conclusion that contact can be a good thing only if it aims at the truth. 

In our group, we discussed the difference between identity and belonging; some adopted adults wish to seek their identity but not to have any sort of ongoing relationship with their birth family.  Also, the topic of how much support birth parents need.

After lunch, we had two more speakers.  Richard Rose, Clinical Practice Director Mary Walsh Institute, began the afternoon by speaking to us about Life Story Work for Children and Young People.  He introduced us to the work he leads, where severely traumatised children from abuse and neglect, from ages four to twelve, undergo specialist therapeutic treatment based in residential settings.  The work is based on the HIDE approach, where the History, the Internal Working Model, the Development of the child and the child’s Environment are all given equal importance.  The Internal Working Model is based on attachment theory, where the child’s self-belief is directly linked with his belief about caregivers and about the world.  So, if a child feels he is unlovable, he sees adults and the world as unloving and unresponsive.  The life story work consists of a great deal of research taking place, with information-gathering taking place from many sources, until a full picture of the child’s history is obtained.  In the HIDE model, there is an equal emphasis on therapeutic input, life story work and therapeutic parenting.  All professionals work together and there is no client confidentiality between them.   It begins with the child and the therapeutic parent with feelings and trust games, then a ‘Bayeux Tapestry’ of the child’s interpretation of his or her life story is made on wallpaper.  A family tree is made, with much story sharing, allowing time to process. 

As with the previous speaker, the emphasis was on truth, and not on presenting children with their histories ‘glossed over’ or ‘made better.’  Richard quoted from Vera Fahlberg (see CfED website for source), which included a striking sentence: ‘Whatever the past was the child lived through it and survived, and so can live with the truth.’ 

The group discussions shared a frustration with the lack of resources in most organisations, but a great wish to apply the sort of best practice of which Richard had spoken with our available resources.

The last speaker of the day was Katherine Green, Senior CAMHS Practitioner and Adult Psychotherapist.  She shared a case study with us, on her theme of Working with Problems of Contact: Developing a Therapeutic Model.  The case study was about a nine-year-old girl, Sarah, who was angry, aggressive, attacking, resistant to therapeutic intervention or to any exploration of her history.  She was an adopted child, with a history of physical abuse and neglect.  Sarah was born with an opiate addiction.  She spent her early years in and out of foster care and paternal grandparents’ home, suffering neglect – an all too familiar story to clinicians who work with this client group.  She held on to an idealised picture of her birth mother, fuelled by her contact with birth family.

Katherine and her colleague embarked on a piece of therapy with Sarah and her adoptive mother where they thoughtfully read out professionals’ notes made on Sarah from her birth onwards.  As they read out often very painful notes, they modelled a thoughtful parental couple, as they commented on how it must have felt for infant Sarah.  Through this process, Sarah gradually became interested in her story and wanted to know more.  Her behaviour improved dramatically and eventually she chose to stop all contact with her birth family, who were untruthful to her and kept alive her false hopes. 

The group discussions continued the theme of the importance of two adults talking and thinking together.  I was put in mind of Leslie’s initial comments about the difficulty of maintaining the depressive position, and how two people are often needed to maintain it when there are such painful, traumatic stories. 

Through this day, we as professionals working with this client population had what felt like a luxurious opportunity to reflect and think together on our practice.  We went away feeling refreshed and ready to continue with our work.    

Angela Evans