A Model for Understanding and Intervening in Hard to Reach Presentations
As a Social Worker in an English Child and Adolescent Mental Health Service (CAMHS) I discovered a capacity to work with children and young people who no one else quite knew what to do with, and who didn’t fit any easy diagnostic or treatment boxes. These I would term ‘hard to reach’, young people, who caused professional and caring adults much worry and often frustration and who presented with a wide range of acting out and acting in behaviours such as aggression, self harm, depression, suicidality and substance misuse. They were often excluded from services and did not want to engage, they believed they did not have a problem and even if there was a problem it was definitely someone else’s fault. Despite this I had considerable success in working successfully with such young people and developed an deep interest in them as individuals and a group.
I spent 8 years at the Tavistock and Portman NHS Trust on a professional doctorate in Social Work trying to better understand this group, the genesis of their difficulties, inner working models, presentations and best approaches. This work appeared to demonstrate that ‘hard to reach’ presentations developed within a context of direct or relational trauma. Central to the model of understanding such presentations is the assertion that they are manifest and need to be understood as having four different characteristics and each of these aspects of Hard to ‘Reachness’ is matched to 4 domains of intervention (see below). For every young person the impact of each of these various factors will differ and this may help to explain the great range of the group and the needs presented.
|Aspects of Hard to ‘Reachness’||Domains of Intervention|
|Biological (stress)||Management and Safety|
A very brief summary
Biological issues are understood within a neurodevelopmental framework including flight, fight and freeze and executive function. This relates to difficulties in emotional regulation, reactivity and thinking things through. Children are often in very basic states of fear and fury and rely on the adults around them to provide safety and containment. They also need opportunities to work off high emotional tension and states and safe risk taking, sport and relaxation can all be helpful in this.
Unconscious processes mean that children and young people are often driven by early experience to function and behave in ways which may seem curious or bizarre to us. They may see other people as either very good or very bad regardless of what they have done and this attitude can switch in an instant or be very fixed in spite of any outside influence. An inability to take responsibility can be core with this group and linked to avoidance of feelings of shame which can also lead them to become quite controlling. There can also be difficulties in knowing what they feel and how to their express emotions and emotional responses may be either non existence, extreme or ill fitting to a situation. As well as not knowing what they feel these children often have a lack or distortion of memory, their histories and past can be vague, muddled or absent and this can often be mirrored in the professional system. With more troubled children this may extend to a struggle in distinguishing between fantasy and reality and it can be hard for workers to discern the reality of what is being shared. Being aware of the metaphor of what a child is saying or doing is important. Story, narrative and creative activities can all help you and the child discover more about them and how to organise themselves and the world. A worker can make meaning or ‘wonder’ what is going on for a young person or how they might be feeling. Quiet moments and spaces can be sought for both the child and worker to allow reflection on what might be going on.
Relational aspects are central in both the development and attendance to ‘hard to reach’ states. Children can present as emotionally and relationally immature and may need to be related to at their level of functioning rather than their chronological age. They often have difficulties with reciprocity and can be very demanding with no sense of relationships being two way. There can also be a tendency to insecure or disorganised attachment styles which can add to further complexities in presentation. I would argue that ‘hard to reach’ ways of being develop in and through a particular relational context and it is relationship that needs to be the primary focus and vessel for reparation. Young people need to be met where and how they are. Relationships need to demonstrate genuine care and concern and to robustly respond to the various challenges which will be presented. This requires clear boundaries and expectations and containment and understanding of both positive and negative states. Meaning and understanding are sought and any consequences congruent and make sense and are not the primary means to achieve change.
An environmental and contextual perspective is crucial with an awareness of both the child’s past and social history and their current circumstances. Wider community and social factors are significant with poverty, social exclusion, racism and gang culture all impacting on life chances and outcomes. A young person’s inner world can easily be replicated in their current systems and workers can fit in with old and often unhelpful patterns. Communication in the network and reflective spaces are required to consider if systems are being unhelpfully impacted and also to allow a sharing of understanding and information to try and get an informed picture of the child in the context family history and present situation.
I believe that these findings are an important contribution in considering our approach to the challenges of helping hard to reach, traumatised and marginalised children and young people. I am seeking to disseminate and develop these ideas through my new organisation Orb8 which seeks to support children and young people, carers, staff, services and networks in understanding and working with such groups to achieve real and lasting change and more information is available at https://www.orb8.org/
For those who want to read my full dissertation it is called; Understanding Hard to Reach Adolescents: A Bio-Psycho-Social Model of Aetiology, Presentation and Intervention and can be viewed free.