Sunday, 6 June 2010

Panic and unthinkable anxiety

Emotional and behavioural difficulties encompass a wide range of difficulties and needs and include both problems which manifest in either emotional or behavioural terms and problems which have both emotional and behavioural dimensions (Maras and Redmayne 1997). At an extreme these difficulties may be experienced as fear and rage and can manifest as violence to self, to carers, to peers, to others. This fear and rage is very like the ‘panic’ states described by Dockar-Drysdale (1990). Both states are similar to what Winnicott (1965) described as state of ‘unthinkable anxiety’. Winnicott spells out these ‘unthinkable anxieties’ or ‘primitive agonies’ as:
• Feelings of going to pieces
• Falling forever
• Having no relation to the body
• Having no orientation
• Complete isolation because of there being no means of communication
(collated in Davis and Wallbridge 1981)

It appears that these young people lack the internal image of arms that can safely hold, of a mind and face that responds to pain and joy – of a mother that can soothe terrors, of a father that can keep monsters at bay. (Woodhead 2001).

Many of the young people with whom we will work are in the care of local authorities and one of the defining characteristics is a seeming inability to tolerate the experience of being cared for in families in the community. Professionals have frequently defined their needs in terms of conditions such as autism, aspergers syndrome, attention deficit, dyslexia, depression, conduct disorder and attachment disorder. They may be regarded by adults as manipulative, attention seeking, irritating, untrustworthy, selfish, difficult and frustrating to manage.

The child’s primary care-giver and the relationships closest to him will have created the images built up. However the inner world soon builds and extends to siblings, friends, teachers and others. A complicated network of personal images of the self and others emerges. For children who experience serious disruption and distortion, it becomes difficult to create such images and sustain a ‘sense of me’ (Ward1998). For children who experience abuse, sexual, physical or emotional, the whole picture becomes distorted and painful (Ward. 1998).

For young people in the care system this can be extremely painful as they also have to bear the feelings of loss. We all experience loss in our lives and many children will suffer the loss of someone close to them, for example a grandparent. We learn to cope with losses such as this, with appropriate support, as part of our development. However many children in the care system will not only have the loss and separation from their families but also loss of foster families, as the breakdown of foster placements is an all too familiar event. I have worked with young people who have had as many as seventy different foster placements. How can these young people gather together experiences into any meaningful or positive whole? They don’t, they become numb to any further attachment, to protect themselves from further pain.

Unintegrated young people will not have experienced a meaningful attachment, for them loss will more likely to be experienced as instinctual painful feelings which they most likely will not be able to acknowledge or express in any way, they do not know how to grieve, they are more likely to experience rage and envy. These feelings of rage and envy will often be ‘acted out’ when triggered by something else disconnected from the original feelings. This ‘acting out’ behaviour happens because the child has no other way of communicating. Dockar-Drysdale (1990) states that all ‘acting out’ is a breakdown in communication and it is the responsibility of the worker to keep in communication with the child. She discusses the importance of being careful to respond when the child reaches out to us. This is what Winnicott described as the most important thing in the child’s early emotional development, the sensitive response of the primary care giver, to the child’s needs.

If we are going to be able to help these children we need to be clear about the task. Understanding a child’s early primary care experience helps us think about their present needs. Learning to deduce the emotional content of the child’s early experiences provides an understanding of each child. We need to help the children come to know, that their needs will be met within a consistent containing predictable and loving way. This is essential in the therapeutic task.

Holding and containment provide a safe world with boundaries, within which relationships with others can be negotiated. Children who have not experienced sufficient holding and containment demonstrate this with chaotic and disruptive behaviour. A major part of the task is then to provide a safe world where they can develop a secure base on which to grow.

The holding environment and therapeutic childcare
Winnicott (1965) used the term ‘ holding environment’ to refer to the totality of the parents’ provision of physical and metaphorical holding of its emotional well-being. This metaphor has been extended to incorporate the total treatment environment in which care and treatment is provided for in a range of residential settings including children’s units.

The holding environment will consist of a number of key elements:
• Provision of appropriate boundaries on behaviour and expression of emotions, strong feelings can be expressed but do not get ‘out of hand’.
• Providing an element of ‘giving’ and tolerance in relationships, so that people will feel genuinely cared for and where appropriate, looked after; the ‘giving’ in the relationship may also include some degree of interpretation or at least ‘reaching out’ in communication.
• Appropriate containment of anxiety (see Bion 1962) for example the adult can take the anxiety on for the child, conveying to the child that the problem will be managed by the adult and child together until they are able to manage it alone.
• Working towards maximum clarity in communication. Misunderstandings need to be resolved. People under stress may interpret things in a distorted way. People feeling ‘unheld’ may feel undervalued or persecuted. (Ward, A.1998 and 2003).
• We must also take into account the provision of appropriate ‘holding’ for the staff team who are engaged in the ‘holding process’. The quality of the ‘holding environment’ of staff is the determinant of the quality of the holding environment for the children. This is created by the organisation and the process of management. (Miller 1993).
• The ‘culture’ in which thinking is embedded. How physical and structural holding mechanisms are understood and founded on staff thinking together (Ward, A. 2003).
• The children need to feel they are being held in mind. Care and thinking needs to be underpinned by what Winnicott calls ‘primary maternal preoccupation’ (Winnicott 1958). That is in order to develop mentally one must not be forgotten.(Ward, A. 2003).

Managing violence in children and young people
Winnicott argued that unintegrated children cannot contain violent feelings. We need to help them to communicate, by listening and responding appropriately. The therapeutic task at this stage is to hold onto the child, survive the attacks and manage the behaviour, until they can begin to control themselves.

In a lecture on deprivation and delinquency and work in substitute caring, Winnicott (1970) shortly before his death said, ‘it may be a kind of loving but often it has to look like a kind of hating, and the key word is not treatment or cure but rather it’s survival. If you survive then the child has a chance to grow and become something like the person he or she would have been if the untoward environmental breakdown had not brought disaster. Children who have experienced trauma and environmental breakdown need adults who can allow them to process their rage and who can survive their angry attacks.

All children and young people who enter substitute care require the most sensitive understanding of their difficulties experienced in their development. Bettelheim (1950) in his book “Love is Not Enough” stated that love alone would not effect change in working with disturbed children and young people. If they have the opportunity to change they have to be able to express and work with their destructive, hateful feelings and they have much to feel enraged about. The roots of their disturbance, and the intensity of their pain and the powerful effects it has on others needs to be understood and survived by their substitute carers. For their pain to be relieved and their development to be freed, they need an approach which is sensitive to their inner world.

Assessment of integrated/non-integrated child
The un-integrated child shows both panic and disruption
Panic, often described as a temper tantrum, is the hallmark of un-integration. It represents traumatic, unthinkable experience at an early age. It produces claustrophobia, agoraphobia, states of disorientation, and a total loss of identity. The victim may become immobilized in a state beyond terror, but is more likely to hit out, scream, destroy things and attack other people.
Disruption, often described as anti-social behaviour, is easily recognized. The child comes into contact with other, functioning children and immediately, compulsively breaks into the group and breaks up their activity (work or play). Un-integrated children break down into violence at times of total disintegration. They cannot contain violent feelings. It is only possible to accept responsibility with a functioning ego. This is not present in these children, and therefore, the staff have to supply the functioning ego themselves, and hold both the child and the violence together.

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