The Child and Reality

Lectures by a Child Psychiatrist

T.A. Ratcliffe

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429810442
• Subtopic: Mental Health in Psychology
• Index: Psychology

Dr Ratcliffe had long experience lecturing to a wide variety of audiences as a child psychiatrist. This title, originally published in 1970, is a collection of twelve of these lectures, given by him on various 'special occasions' during the years prior to publication, in which he emphasized the importance of environmental factors in understanding and working with children.

The subjects include residential work with children, school phobia, adolescence, the problem family, relationship therapy and casework, the three-generation family, and child guidance techniques. The final chapter, based on a lecture originally given in the early years of the community mental health and social services, makes particularly interesting reading in the light of subsequent developments in these services.

At the time this book would have been of great interest not only to professional workers, including doctors, teachers, child care officers, residential staff and health visitors, but equally to the student in each of these fields, and to the lay person who is genuinely concerned with children – and adults. Now it can be enjoyed in its historical context.

Chapter I

Residential Work with Children
Treatment or Training—Is there a Difference?

It is a remarkable but relevant fact that it should be considered necessary by those with many years’ experience in residential work with ‘maladjusted’ children to discuss these two alternative forms of help for such children as if there were always these two completely different alternatives between which one must choose in each case. Even more significant is the subtle implication in our thinking that ‘training’ is always of inferior status in comparison with ‘treatment’. Yet there are understandable reasons for basic attitudes such as these.

All professional workers tend to over-use, and misuse, ‘jargon’; and, in particular, to give special technical meanings to words which have another significance when used in ordinary conversation. Consequently, there is often considerable confusion as to what each of us means by ‘treatment’ or ‘training’.

Secondly, there is a very wide range of differing types of residential unit. In part such differences stem from the varying roles and personalities of those in charge of individual units; but, more importantly, each individual unit has tended to ‘specialize’ in a different type of problem, and thus choose the type of child whom that particular unit can help most effectively. This high degree of specialization is one of the most valuable, and necessary, features of residential work in this country; but it also means that each of us will tend to regard his own personal techniques of training or treatment not only as the most genuinely suitable for the children in his unit, but also as the ideal for all other units equally.

The problem can be vividly illustrated by considering the question of treatment in its narrowest, psychotherapeutic sense. It has been estimated that, in the average local education authority hostel, less than ½ per cent of the children in that type of setting will require long-term intensive psychotherapy (with an additional 5 per cent who may need skilled professional counselling help from time to time). In a hospital children’s or adolescent unit, their higher proportion of deeply disturbed patients will mean that psychotherapy is much more widely needed and used. Finally, in those one or two schools which specialize in, and therefore select, only children with deep neurotic disturbance, the proportion of children requiring intensive psychotherapeutic treatment may rise virtually to 100 per cent.

Few workers in this field, and certainly not I myself, would deny the necessity for such forms of treatment when these are needed. Nevertheless, it is equally essential to remember that, for the majority of children in this type of special school, hostel or unit, the ‘treatment’ of choice is not psychotherapy but that form of help which has been described as ‘relationship therapy’ or ‘environmental therapy’. That is to say, the deliberate development and provision of a regime and setting within which, and because of which, the child can mature and adjust both happily and successfully; and within which he (or she) can build up satisfactory relationships both with adults and with his own peers. There are indeed two important basic reasons which justify this types of help as the treatment of choice, in the great majority of such cases.

Children, and even more so, adolescents, tend to act out their problems and difficulties in real life situations rather than to verbalize such difficulties in the way which many adults do. It would be wrong to deny the significance of unconscious factors when working with children; but it must be remembered that youth is much nearer to a normal use and understanding of fantasy than is the adult; and the child’s defences are much less sophisticated and elaborate than these will be in adulthood. Consequently, when one is working with children, it seems reasonable to attribute relatively much greater importance and significance to reality factors than to unconscious ones.

Another important factor is that the only really positive criterion to justify any sort of residential placement for a child is that the placement chosen can provide something which the child needs, but which cannot be provided, even with help, within the child’s own family home. An obvious example of this principle is that one would not (or, at least, one should not!), admit a child to a paediatric hospital unless he requires some form of nursing, treatment or investigation which would not be possible in his own home. This same basic principle applies equally to any form of residential placement for children. What otherwise ‘unobtainable’ form of help do we therefore try to offer to the maladjusted child when we advise on residential placement for him or her?

The short and simple answer to this question would be that we try to provide a good adult contact; or, in rather more sophisticated terms, we aim to provide an additional (or substitute) parental image and relationship. Yet these apparently simple provisions require careful analysis before they can have any real meaning or purpose. Perhaps, therefore, it would be more accurate to say that the aim should be to provide those parts of the parental image, and those parts of the child’s past environmental experience which have been defective or missing.

For the severely deprived child, this may involve the provision of a permanent and total substitute mother-and-father relationship. But for some children and especially for those whom we aim to return to their own families in due course, the need may well be to provide temporarily a more suitable father-figure or mother-figure; and here one must always clearly bear in mind the very differing roles of a mother or a father vis-a-vis infant, or child or adolescent. More often still, it may be one part of the parental image that is defective. Has this adolescent lacked the necessary authority aspects of the father’s role; or this small child the equally necessary protective role of the mother ? Has this teenage girl had no adult male figure with whom she can safely and securely ‘flirt’ and try out her developing femininity ? If so, must not the residential unit provide just these requirements ?

Similarly, on the general environmental side, the child or adolescent may have lacked adequate ‘cultural’ stimulus; he may have been pushed too hard and have had too much demanded of him socially or educationally. He may have grown up in a family which itself had no stable standards, and could set no suitable example for him. Or, perhaps most commonly of all, he or she may have had a lifelong and successful experience of manipulating every situation to his own demands in the face of weak, ineffectual, unsure or inconsistent parental handling.

Clearly very different types of relationship and environmental therapy must be provided in each of these differing circumstances. Yet, even so, each form of treatment or training has one central and essential factor in common. The relationship must be with a ‘real adult’ reacting in ‘real life’ situations. What has been vividly described as ‘synthetic geniality’ will cut no ice at all. Nor will the parental role be of any value if the adult himself behaves immaturely. The teenager who urgently needs (and demands, if most often indirectly) a stable, adult figure upon whom to rely will not be helped if that adult attempts to be a pseudoadolescent himself in order to curry favour or gain popularity. Nor will the substitute (or real) parent succeed if he sidesteps reality situations and difficulties, instead of helping the child, or even more so, the adolescent, to cope with such problems.

‘Real’ people, however, can be cross as well as pleased; can say ‘no’ as well as ‘yes’; and can be disapproving as well as approving as each is necessary or appropriate. Inevitably, therefore, questions of discipline must play an important part in the work of any residential unit.

It is unfortunate that the word ‘discipline’ (like ‘training’) is so often used in a derogatory and condemnatory way. Although discipline is so often, but mistakenly, seen in terms of punishment, restriction and rules, it is, in fact, the achievement of a good and mature balance between necessary freedom and equally necessary control. Obviously it will require the development of an adequate degree of self-discipline based on the individual’s own internalized standards and powers of self-control and self-decision to achieve such a balance in its most complete form. But it is difficult to see how these individual controls and standards can be internalized except on the initial basis of adequate externally imposed standards, encouragement, controls and example within the framework of the child’s experience and relationships. One has only to observe the normal maturation and emotional and social growth of any child to recognize the gradual transition from external to internalized discipline. It seems remarkable, therefore, to suggest that we should deny this same basic requirement to disturbed children in a residential setting, especially since, for a variety of reasons and in different ways, the great majority of such children will have lacked—in part or in full—this essential part of life experience. If a residential unit staff member does not provide this requirement adequately, consistently and firmly, is he providing what the child has so far lacked; or, for that matter, is he being that necessary figure for the child—a ‘real adult’ ?

Few of those with adequate experience with children, would claim that one could successfully ‘bring up’ or help any child solely on the basis of punishments or rewards; but this is not the same thing as saying that such factors and methods do not have a part in the necessary total environmental and relationship needs of the child.

This does not mean, of course, that one must work only within an elaborate frame of rules, or so supervise and control the child that he has no opportunity for experiment or growth. What it does mean is that one balances approval and disapproval against each other as each is ‘earned’; that one knows when to encourage and when to prohibit; when to take action and when to leave alone; and, above all, to know what demands can and should be made on the child in terms of his maturity, his capacity and his needs at that moment of time. Any setting which is to achieve this must be reasonably structured; but the essential aim is to provide, maintain and indicate clearly the boundaries of acceptable behaviour (in the widest sense of that word), thus creating a known framework within which the child can experiment securely and learn how to cope successfully, and without excessive anxiety, with problems and stresses which are within his capacity at that stage.

It is also important to recognize that, in a residential setting, one does not establish and maintain these boundaries, or build up the necessary child-adult relationship, solely by dealing successfully with a major behaviour crisis—although sometimes this can be a valuable and necessary starting point. Far more frequently, however, it is the way in which the adult handles, and reacts to, the everyday incidents of the living-together situation, and the total regime and ‘atmosphere’ which he creates which are the really significant factors in achieving such success.

It will be obvious that much of what has been described above could be classified as ‘training’. Yet can there be any doubt that it is also treatment and therapy involving a very high order of technical skill ?

Where does the child psychiatrist (who for so long has seen the therapy of the disturbed child as his own private province) stand in all this ? Certainly he will have to come out from his ivory tower, and learn to recognize, and to respect, the treatment skills and roles of workers in residential units. He must willingly accept that his own treatment function vis-a-vis the individual child in such a setting will be a small and limited one. But this is not to say that he does not, or should not, have another equally important task.

Like every other specialist, the child psychiatrist has two separate, but closely interrelated, professional functions. First he must assess and select such children as need his particular treatment skills; and provide that therapy for them. But his second, and consultative role, is the more important in the situations with which we are here concerned.

If the residential worker is to carry out his complex treatment task as we have described it here, he (or she) must be a stable adult who has worked out his own attitudes (and prejudices) maturely and with insight. This raises the issue of good selection of such workers—and one could spend a whole conference on that topic alone! Equally one could, and indeed should, give detailed thought to the structure and type of staff training courses which would best increase both the technical skills of residential staffs, and their insight into human motivation and behaviour. Yet even if we ever achieved this standard of good selection and well-balanced training, the consultant would still have a vital and necessary role.

Residential work with children is a very demanding task in which one is ‘giving’ a great deal; and however well-integrated the unit is within the local community, it is also a very isolating task. For this reason alone the understanding visitor ‘from outside’ has a valuable function for staff morale. But the consultant’s real role goes more deeply than this.

Whilst it would be generally agreed that the residential worker must avoid a too intense or too deep emotional entanglement with the child whom he hopes to help, some degree of emotional feeling and involvement may well be a vital factor if such help is to be really effective. Moreover, however carefully the worker preserves his own professional attitude, he will still have to be aware of, and cope with, the child’s natural feelings for him whether these be negative or positive.

In practice, this delicate balance between too much and too little involvement is almost impossible to achieve in a residential setting without the help of a skilled and understanding ‘outsider’. There will be other and equal complex decisions to be made; when to intervene and when to leave well alone; when to prohibit and when to encourage; when to be protective and when to push; and many others. Moreover, each of these decisions has to be made in terms of the individual child’s needs at that particular moment of time; and within the emotionally changing dynamic pattern of the residential community.

Although it is, and indeed most often should be, the worker who has to handle these actual day-to-day situations, the child psychiatrist, with his specialized knowledge of human behaviour and motivation, and his relatively more ‘detached’ view of the total situation can provide insight, confidence and support to the worker in his task. He can provide the ‘diagnosis’ upon which the most appropriate ‘treatment’ can be based.

It would be inappropriate to discuss in detail here the child psychiatrist’s total consultant role or his own relationship with the children; but certain essential features must be noted.

Quite often, indeed probably most often, the psychiatrist’s contribution may appear to be a ‘negative’ one in that he is stressing that this is not a psychiatrically sick child. Yet, if the worker can be helped to accept this reassurance, he can apply with confidence his techniques of handling the ‘normal’ child. Equally importantly, the psychiatrist, in explaining the child’s behaviour and its motivation, is not excusing that behaviour. In other words, he is stressing that normal guilt and normal anxiety are constructive mechanisms which are necessary for satisfactory character and personality growth.

Nor is it the child psychiatrist’s role to tell the residential worker how he should handle the situation, or the child, but to help the worker to use his own skills, insight and ability more confidently and successfully.

If we are to achieve real co-operation—and without such co-operation the whole enterprise will fail—there must be mutual trust in, and respect for, each other’s skills and personalities; and an ability to accept genuinely not only each other’s limitations and strengths, but our own limitations and strengths also.

Chapter II

The Therapeutic Team in a Residential Hostel Setting

All professions build up a technical language of their own which is then valuably used as a means of communication within the specialist group; but the boundary between a constructive use of technical jargon, and its misuse, is a narrow one. It is, therefore, dangerously easy to overstep this boundary without our recognizing that we have done so. We can become so accustomed to using our jargon phrases that these end as a series of cliches about whose original meaning we have long since ceased to think. In my own speciality, for example, the phrase ‘the deprived child’ had a specific, important and limited significance when it was first brought into use. Now it is often used loosely to mean any child who is deprived of almost anything that the speaker thinks he ought to have. There is an even more dangerous risk, however, when our jargon is given a ‘mystique’ of its own: or if we give it our unthinking acceptance, and do not analyse just why we are doing so. That now popular jargon term, ‘the team approach’, has suffered this fate to become one of the ‘sacred cows’ of quite a number of professions. But what exactly does this term mean, and imply, for the actual members of the team?

It might be valuable, therefore, to examine the team approach as it works, within my own experience and in one particular residential setting. Two colleagues and I described the detailed working techniques and role of the hostel in question in a paper published some years ago.¹ Although, as a necessary framework for my comments, I must provide a brief preliminary note about the basic function of this hostel, I do not propose to repeat here the very detailed description which was given in that paper. My aim on this occasion is to consider how the roles of the various members of...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Author’s Introduction
• Acknowledgements
• 1 Residential Work with Children—Treatment or Training: Is there a Difference ?
• 2 The Therapeutic Team in a Residential Hostel Setting
• 3 Truancy, School Phobia and School Refusal
• 4 The Three Generation Family
• 5 The Problems of Normal Adolescence
• 6 On Working with Young People
• 7 The Quality of Parenthood
• 8 Evaluation with a View to Action (The Diagnostic Role of the Child Guidance Clinic Team)
• 9 Relationship Therapy and Casework
• 10 The Problem Family—Personality Factors
• 11 Specific Aspects of Health Education—Preventive Mental Health for the Teacher and Doctor
• 12 Community Mental Health in Practice