This paper by Victoria Faulkner – Barrett, who is a Therapeutic Care Worker at the Mulberry Bush School, is a final year assignment from our Level 5 Foundation Degree in ‘therapeutic work with children and young people’ accredited by the University of the West of England.
The Mulberry Bush Organisation, a Non-Maintained Residential Special School for children with severe emotional and behavioural difficulties was established in 1948, founded by Steven and Barbara Dockar-Drysdale. The school offers 38 week provision for children aged five to thirteen years. Comprising residential and educational facilities, children are placed at the school by their Local Authorities for an average period of three years. Throughout this reflective case study I share experiences from within my role as a Therapeutic Care Worker in the Group Living Department, where there are four residential houses.
The study examines the use of a Behaviour Management Plan for a child Jake, the antecedents for this intervention and subsequent impact within the organisation. In order to create a greater learning opportunity, there is less emphasis on specific practical elements of the provision and more research into the anxiety and group dynamics present. Thought is provoked as to who benefits most from a prescribed Behaviour Management Plan within the residential setting. The conflict between the psychodynamic principles underpinning the work within The Mulberry Bush, and behaviourist approaches are considered; concluding with a decision as to whether there is a legitimate need for the provision along with recommendations of what form this should take.
Why this area for focus?
This particular area of work roused my interest from the first year within my role. The way seemingly “high profile” children such as Jake and the way their provision powerfully impacts relationships, individually, departmentally and interdepartmentally fascinated me.
I found myself burdened with difficult feelings where there appeared to be a clash between psychodynamic and behavioural approaches when supporting children’s challenging behaviour with the use of a Behaviour Management Plan.
There were times that I found myself “lost” in Jake and caught up in difficult group dynamics when involved with his provision. This study enables me to reflect upon these experiences and make more sense of them, which at the time seemed impossible.
The Task and Method of Study
By exploring some of the theoretical concepts relevant to the work surrounding Jake, drawing on related literature and reflections from within the organisation, I highlight ways in which Jake’s individual Behaviour Management Plan has benefitted the therapeutic intention. Allowing further thinking, I am then able to identify areas where I am confident we have the opportunity to gain experience and learning for the future. In doing so, I offer proposals of how this learning can be implemented practically within the residential setting.
Whilst there are a vast number of theoretical frameworks that can be drawn upon, this study will focus primarily on emotional containment. The link between the theory of containment and group dynamics observed between adults and children within the Group Living and Education Departments are also a focus for study and reflection.
By approaching this study from a qualitative perspective I will be focusing on the behaviours and communications of practitioners and children, supported by personal reflections, meeting minutes and experiences of working alongside Jake.
An awareness of the limitations of this approach is important. The information has been gathered from a single source, within the organisation of which I am an employee. I have also worked closely alongside Jake for a period of two years. There is a risk that this will impact on my ability to maintain an objective position. Being consciously aware of the possible impact on the study, using the support of my peers whilst making appropriate use of my individual supervision (a space provided to reflect on the impact of the work), I aim to manage this limitation.
There are ethical implications which need to be considered and acted upon. Confidentiality and anonymity have been maintained throughout by using pseudonyms for both children and staff.
Permission has been sought from the Head of The Group Living Department, allowing this study to refer to conversations and meeting minutes where necessary. In line with legal and ethical guidelines all details which could compromise the identities of those involved have also been changed.
So, who is Jake and what is a Behaviour Management Plan?
Jake is twelve years old and lived with his birth mother and half sibling until he was seven years old. Prior to being placed with Foster Carers, Jake experienced severe neglect and witnessed domestic violence within the family environment. He was regularly missing from home with a lack of adequate supervision and appropriate boundaries. There is evidence that Jake may have been subjected to physical abuse and through multiple generations the family has been observed as being dysfunctional. Jake’s Father was convicted of rape and sentenced to nine years in prison in 2004.
Jake who is diagnosed with an Attachment Disorder, was placed at The Mulberry Bush School a month prior to his tenth birthday and experienced a number of family and school placement breakdowns prior to this. Since July 2011, Jake has been successfully placed with long term Foster Carers.
Displaying toddler like behaviour and exhibiting high levels of physical aggression towards adults and other children which can be unpredictable, Jake will try to control all aspects of his provision and play.
There are gaps in Jake’s education although is considered to be academically able, he is unable to take instruction in the classroom environment. This will manifest itself by Jake becoming challenging, making it unsafe for him to be alongside the group.
Due to the high levels of aggression, staff anxiety and incidents where physical restraint became necessary, a Behaviour Management Plan (Appendix 1) was put into place. The aim of this plan is to:
“(…) outline measures being taken to support Jake through the daily routine in the house and class; specifically noting the actions to be taken when his behaviour causes significant distress or disruption to himself and others”
(Mulberry Bush Organisation, 2014)
Early experiences of working alongside Jake
“I can’t stand to be alongside him [Jake] he makes me feel small. He walks into a room and I feel anxious, but who for? Him, myself, the other children, the other staff? I have a physical feeling of being frightened, but of what? Being hurt by him, but also the consequences of not being able to stop him. It feels as though I have shared my anxiety so many times, nothing is being done. The other children are terrified of him and most of the time he seems terrified too!”
In this abridged extract from my Reflective Journal I write about my feelings from a shift within the first few weeks of Jake joining our child group, my views appeared to be shared by the team. Minutes from the team’s first Children’s Meeting describe Practitioners feeling, “scared, confused, exhausted, isolated, emotionally drained and stuck.”
I remember these feelings being intense and at the time questioning my ability to work alongside him without becoming completely overwhelmed and/or breaking down. There was a sense of being “done to” and that having to endure Jake was someone’s fault, it felt as though there was an expectation for us to relentlessly carry on.
This led me to realise I was not contained, and neither were the teams working with Jake. It is possible that in the early stages of his placement, the organisation as a whole experienced a lack of containment. Then came the realisation in my Reflective Journal, Jake was in the same position.
“If we are scared of him [Jake] and he is scared of himself then where does that leave him?”
It was shortly after this that a Behaviour Management Plan was implemented.
“There is now a plan [Behaviour Management Plan] in place. It was too much, I don’t know if he will stay or if we are the right placement for him but it seems like we have a way forward now.”
Whilst these details are limited to a narrow margin of reflection in terms of the events leading up to a structured plan being executed, the aim is that they will help to inform the subsequent areas of this study. By reflecting on feelings of being alongside Jake in the early stages of his placement, and nearing the end of his time at The Mulberry Bush later in the study, it allows an insight into his emotional progress and my own professional development.
I was interested to discover that there is limited literature providing information about the use of Behaviour Management Plans in a therapeutic residential setting. Focusing my literary search on anxiety and emotional containment, bringing these together with group dynamics within the organisation I have been selective in my research as the area is potentially vast.
The Behaviour Management Plan as an Emotional Container
The Behaviour Management Plan in place for Jake provides guidance to support him through disruptive or aggressive behaviour. The common theme within the plan is his removal from the group if he is unable to engage in the limited choices he is offered following him becoming non-compliant, disruptive or aggressive. There are also set periods of time that he is required to be separate from the group following incidents of varying levels of seriousness.
When looking at the concept of Containment it is useful to consider its definition:
“The action of keeping something harmful under control or within limits”
(Oxford Dictionaries, 2015a)
When applying this definition in the context of working alongside Jake, the anxiety and the emotions that he experiences could be “harmful” and the process of these anxieties being kept “under control” could be represented by the Behaviour Management Plan in place.
Bion (1962) describes the process of containment as an interaction where the infants unmanageable feelings are “projected” into the caregiver so that they can feel them on their behalf before handing them back in a more manageable form. Being aware of Jake’s early experiences of trauma, rejection, neglect and abuse it is unlikely that he has experienced this “holding environment” as described by Winnicott (1965) where a stable, dependable and structured environment allowing for nurture and security is created. Jake’s “inner world”, a sense of “self” or identity, developed through his early experiences of his primary caregiver (Bowlby, 1969). Via this “internal working model” he is provided with a prototype for future relationships. This is therefore likely to be confusing, chaotic and unbearable to tolerate as his adaptation of the working model is disorganised, where early primary caregivers are seen as frightening or frightened and the child is either helpless or in Jake’s case
angry and controlling (Howe, 2000). The challenging behaviour displayed can be interpreted as a form of communication of these unmet needs and as a “symptom” of his diagnosed Attachment Disorder.
So, if the aim is that we are able to provide containment for Jake, how is this provided through the use of a Behaviour Management Plan? It is important to note that within the residential setting there are many ways in which we offer containment; Jake’s Behaviour Management is one part of a collaborative and holistic approach in order to facilitate a greater level of emotional containment where these unmet early needs can be experienced in a symbolic way.
Geddes (2006a) discusses the need for a reliable and predictable routine offering consistency. Geddes shares her experience of the reduction in anxiety in both child and practitioner, lessening the need for hyper vigilance in the child to the risk of danger in a controlled environment. Having a Behaviour Management Plan supports this view, by providing a consistent structured routine and having specific adults alongside Jake reduced his anxiety of not knowing what, or who was coming next. This containing structure was also experienced by the Practitioner.
It is my opinion that we need to avoid falling into a pattern of becoming too structured in our approach. There are elements of Jake’s provision that could be considered heavily structured and boundaried with an environment seeking to achieve over compliance. This is where I experienced a personal conflict, feeling that the provision was becoming less therapeutic and potentially more punitive as time went on. If we consider the use of the word “Management” as defined by Oxford Dictionaries (2015b), “The process of dealing with or controlling things or people”, I argue that a Behaviour Management Plan suggests that the unwanted behaviour which we have already considered as a communication of Jake’s unmet needs from a psychodynamic view, can be simply changed or halted.
The Behavioural Model was the primary paradigm in psychology between 1920’s to 1950, and is concerned primarily with the observable and measurable aspects of human behaviour. Therefore when behaviours become unacceptable they can be unlearned. Behaviourism views development as a continuous process in which the child plays a relatively passive role and is a general approach that is used in a variety of settings including both clinical and educational. The psychodynamic view criticises this approach due to its failure to take into consideration unconscious processes, relationships and early experience. Toch (2008) when considering the use of a Behaviour Management Plan states that they are usually defined by the staff members who use them, as managerial or treatment interventions but that they tend to be experienced as punishments by the client group.
When staff manipulate measures within Jake’s plan (such as being separated from the group) as a threat or a tool to manage misbehaviour which challenges or disrespects their authority, the practicalities of the plan begin to serve a punitive function. As the plan appears to “work” in the short term Toch goes further to say that with repeated deployment, their long term impact is counterproductive as the clients find themselves labelled, being “picked on” and singled out by their peers. There is the possibility that within The Mulberry Bush, where the children are considered to display the “worst” cases of behaviour, that a Behaviour Management Plan certifies the child as “the worst of the worst” therefore recreating the experiences of them being the “problem”. Jake is predisposed to a valency for rule breaking, aggression and antisocial behaviour, an expectation to “control” this behaviour could encourage a negative cycle potentially penalising him for symptoms that are exacerbated by the use of a Behaviour Management Plan.
Whilst working with Jake I experienced an expectation to “control” him in line with the “rules” of his plan, this left me feeling overwhelmed (uncontained). Where children feel that physical boundaries and external control allow the environment to appear stable and secure, they also learn that staff are bigger and stronger than they are resulting in a lack of containment on the occasions where they win the “battle for control” (Durrant, 1993). In this situation both the child and practitioner can be left feeling uncontained as the practitioner feels defeated and deskilled. I witnessed and experienced this regularly in the early part of Jake’s placement. As the plan has changed in the latter stages of his placement, moving towards it being supported primarily by the Education Team, he often fights for control over the provision with staff who appear intimidated of him whilst being compliant with adults whom he has experienced as being more confident and physically able to manage his behaviour.
The plan also prescribes a high level of physical containment, through areas of the school and physical intervention when circumstances require it. I am confident that in Jake’s case the need for a high level of physical containment was necessary before any level of emotional containment could be experienced, a view supported by Cash (2002). The physical nature of the school was potentially Jake’s first experience of a “secure base”, providing a high level of physical containment for long enough to then look towards relationships as a source of emotional containment (Geddes, 2006b).
Whilst there is strong evidence and I agree that the Behaviour Management Plan serves a containing function, I question how “real” the plan is and how long it should continue without it becoming a “go to” tool that limits our creatively whilst working alongside Jake. Containment and holding by themselves cannot necessarily produce improvement in all cases and I agree with Rustomjee (2007) who claims there is an “absence of reality” in both processes. The appropriate use of containment, combined with well-timed interpretations and the introduction of reality is where best results are likely to be gained.
Following the successful implementation of the Behaviour Management Plan we saw a decrease in Jake’s negative incidents and he quickly began to spend more time in class with less adult support. I would argue that this was not well timed, as we saw Jake once again becoming overwhelmed by the group and his environment leading to the reintroduction of the plan. Frustrations within the staff group increased and Jake’s behaviour deteriorated further as he experienced the “failure” at having to be back on “a plan”. This failure could well be his, but could also be the projected feelings of the Practitioners who also felt a sense of failure. The plan has now been in place for the length of his placement, is this a result of the anxiety of repeated failure or concerns about Jake’s regression if we reduce the use of the provision?
I found the idea interesting that one area of containment must precede the other and that there may be an “order” in which containment should be achieved. I thought back to my earlier reflections of Jake when he first moved into Sunset House where we were unable to contain him due to being uncontained as an organisation, teams or individuals. If a part of his network is left feeling uncontained how are we able to contain him, and how do we work together to avoid him falling into the “gap” this lack of containment creates? This idea is concerned with the anxieties and dynamics present within the staff groups and about the fluidity of these throughout Jake’s placement.
Experiences of working alongside Jake nearing the end of his placement
“The plan initially seemed to provide some calm, but the storm has returned! I think it has a lot to do with his [Jakes] relationships. Education seem to be really struggling with him, he is all over the place. I remember being in the same position, but at the time there was no one with any sort of relationship with him. I have thought that we [Sunset] are at a completely different place in our relationship with him. If this is the case how is his progress measured in terms of his plan? Are we all working within the same consistent boundaries or is there more flexibility as he uses his relationships? Is he stuck? They [education] seem reluctant to acknowledge my frustration. I feel that I have a good relationship with him but this is being tested as I am forever on his case as they seem to allow him the freedom to hurt and be disruptive. It is really difficult to hold onto his progress with this going on”
This extract from my Reflective Journal shows how the dynamics within and between the Teams have changed since Jake first moved into Sunset, and how the level of containment has shifted as his relationships have evolved. In terms of considering my personal development, I think that I am now more able to relate to the impact I have on Jake and the role I take in relationships.
Minutes from the Children’s Meeting offer reflections of the team:
“There is individual work going on away from the group with Jake which doesn’t reflect his progress to him. Are we struggling to hold onto his progress? He is making lots of decisions and adults are not taking control of his plan but he is more able to accept consequences for his actions and apologise for them and is more orientated towards a nurturing relationship.”
So whilst there is tension and some difficulty surrounding his provision, there is also a sense that he has made a huge amount of emotional progress since its inception. This feeling seems limited to the Group Living Department which leads me to wonder how collaboratively we have worked with the Education Team, and if we have tried to hold onto all the progress he has made, a feeling that we aren’t able to “share” the success?
It is evident that Jake has a complex history and he will inevitably carry his early life experiences into groups. In order for the staff group to make sense of what is going on, we need to have developed open and honest working relationships so that tensions and difficulties within the workplace can be talked about and not acted out by either adults or children. As Practitioners we also need to be aware and open to how our own experiences impact on our ability to work with such challenging children.
Children such as Jake have the capacity to challenge the containment of staff to unbearable limits resulting in a sense of desperation which is evidenced by extracts from my Reflective Journal and a view supported by Turberville (2006). The result of these feelings is that the child is perceived as “uncontainable” and attracts the label of being “high profile” and standing out within the organisation.
It is through being contained by a Behaviour Management Plan in the early stages of his placement that Jake may have experienced what Dockar-Drysdale (1990a) deemed “normal social demands” being removed, being treated individually leading to a period of what she described as “quiescent”. These are also times where Jake feels enormous anxiety at feeling different and having a “special” provision. Main (1989) explores the dynamic surrounding these “special children” as the level of their challenging behaviour separates them from their peers. This could manifest itself into having a special provision such as a Behaviour Management Plan which perpetuates the cycle of feeling different. In this way Main also considers how these children often have a small number of staff able to “connect” with or contain them. I question whether this is a product of the provision whereby Practitioners were regularly “told” that they would be supporting the plan. I found myself in this role with Jake, which elicited difficult feelings and dynamics.
“Jake is controlling his plan and is picking and choosing when he wants to be in class, everyone seems to be okay with this? I feel frustrated and as though all the hard work is being negated. He made so much progress but is now rarely in class and isn’t “owned” by anyone. He is not part of one class group; I have shared these difficult feelings which have not been acknowledged. It feels like I am fighting with him constantly on behalf of education and fighting with education all at the same time!”
This splitting of the departments could be as a result of Jake re-enacting his early experiences and the neglect that he suffered, allocating the “bad” qualities into the Education Department and the “good” qualities into me and the Group Living Department. Jake’s limited ability to invest in a balanced relationship where this anxiety can be contained manifests into Jake communicating in violent and disruptive ways which have been observed increasingly in the education setting. As Jake’s behaviours are not being tolerated consistently there is a collusion in the splitting, allowing the difficult feelings to sit within the relationships. By allowing this re-enactment of projections from Jake we limit the capacity for a thoughtful response which has the potential to compound his existing deprivation (Emanuel, 2002: Klein, 1959: Sutton, 1991)
As the focus of the plan has shifted more into the education department where Jake is becoming more disengaged, I question if this is the result of the team around him feeling less contained and more intimidated by him. Jake therefore feels uncontained as his communications are not being held and managed.
The frustrations towards the collusive behaviour of education staff are a common theme in my Reflective Journal. This “Collusive Anxiety” arises where adults are reluctant to challenge Jake’s negative behaviour as he resists his plan and as a result of being afraid of his potential violence in an attempt to reason with him and keep him “calm”. There is the potential that we rationalise his behaviour and collude with him in this way leading to further confusion and inconsistency which we have already highlighted as being a key factor in enabling him to feel contained (Dockar-Drysdale, 1990b). This collusion also compounds the “split” between the two departments as one feels that consistency is being compromised by the other. There is potential for the roles to then become reversed where Jake perceives the Education Team as the “good” and the Group Living Team as the “bad”. McMahon and Ward (1998) describe this as the process whereby what is meant as empathy or a version of preoccupation becoming an unhelpful “collusive merger”. It is likely that this is as a result of the Education Team being at a different stage of their relationship with Jake and that they are experiencing the difficulties and feelings that the Group Living Department experienced at that same stage in their relationship with him. Whilst the Education Department are now “holding” the majority of the plan it is also likely that they are experiencing the same projections that we felt from other parts of the organisation when we were finding our way with Jake.
By studying the evidence available and from my own reflections and experiences in relation to Jake’s Behaviour Management Plan, I am able to offer recommendations for future practice.
The first recommendation is for the term “Behaviour Management Plan” to be changed to “[Childs] Support Plan”. Alternatively a suggestion would be to make more use of the “Positive Handling Plan” already implemented within the organisation, although I feel that this terminology could be perceived as being institutionalised and impersonal.
I feel strongly that the children should not be labelled as being on “a plan” but that they should experience the consistency that comes with there being a set of guidelines for staff to support their individual challenging behaviour. In this way all children experience the differences in their treatment without feeling they are “the worst of the worst”.
Guidelines and/or a Policy developed for the use and implementation of this type of provision would include a monthly review so that the measures of support don’t become “stuck”.
A further practical recommendation is for there to be consideration for the Treatment Team of seemingly “high profile” children to be more fluid in the early stages of their placement. This will allow for staff with more significant relationships (if not the Key Worker) to be able to share their experiences at a more inclusive level.
It is evident that the use of a Behaviour Management Plan has provided a level of containment for Jake throughout his placement. I feel that this containment is a direct result of the staff group feeling held by the provision, the implementation of the plan serving as an acknowledgement that working alongside Jake is challenging and at times painful. Whilst the “answers” are not provided in the plan, it offers consistency that benefits the therapeutic intention.
I conclude that this method is necessary, with an increased awareness around the terminology and language used serving as a reminder of the task. The provision is not a standalone tool and the staff team can only remain emotionally resilient if they are open, and prepared to explore their part in the dynamics within relationships across the organisation. The level of containment experienced as a result of the plan by both Jake and Practitioner have an impact on each other and the dynamics between the relationships, neither are mutually exclusive. Any breakdown in communication between or within the staff groups serves a destructive function and has potential to recreate the early experiences of the child resulting in further deprivation. There needs to be an awareness of the potential that such a structured tool can become punitive and has the capacity to negatively raise the profile of the child, by being in touch with these possibilities the provision should be carefully monitored. It seems as though the actual plan in place is less important than the quality of the communication that is present around the child when considering the emotional progress of the child and resilience of the staff team.
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Jake Behaviour Management Plan
The aim of this behaviour management plan is to outline the measures being taken to support Jake through the daily routine in the house and class; specifically noting the actions to be taken when his behaviour cause significant distress or disruption to himself or others. This plan only deals with those situations that are extra ordinary from that which is dealt with daily in the school environment, for further details on managing aspects of Jake’s behaviour please refer to his Risk Assessment and Positive Handling Plan.
Jake can find being alongside a group overwhelming at times and this can lead to him becoming non-compliant and disruptive. Particularly if he feels he cannot escape the situation. At these times it is important that adults recognise the difficulties he is having in the following ways.
- Offer limited choices (no more than 2 or 3) at least one of these choices should be doing something away from the group..
- Make the decision for Jake to not be alongside the group if he is unable to engage in making a choice. Removal from the group does not need to be punitive and should ideally involve engaging him in a regulating activity.
- Return to the group should be no sooner than 15mins and not before he has been calm and engaged for at least 15mins.
Jake can become aggressive when frustrated or fearful; this is often when he is unsure of what is happening to himself or others. It is important to remember that when stressed, Jake can appear to be making conscious choices about his actions however this is not always the case. Particular care should be taken when he is near or around other children that needing physical management.
Under these circumstances he has attacked the adult involved causing significant injury. If Jake is becoming aggressive the following action should be taken.
- Jake should be offered no more than two choices, both of which should involve him not being with the group, one calm activity such as Lego and one active such as football.
- If Jake is unable to engage in making a choice and Jake continues to become aggressive then he should be removed from the group in line with Team Teach and his positive handling plan. Further guidance on using physical interventions can be found in Jake’s positive handling plan.
- For incidents of aggression that do not cause significant injury see stage three for disruption. For those that cause significant injury or that involve a blow to the head the separation from the group should be for no less than an hour, during which time it is expected that he is engaged and calm.
- For incidents of physical aggression regulating activities can and should where applicable be used but do not count towards time spent away from the group.
Reviewed on the 26/11/2014