Therapy is being considered for a boy of 12 who has been neglected and abused but still wants to live with his birth mother. Without therapy his foster placement could breakdown. Mark Drinkwater reports (picture: Narmada Keshav: “Combination of social work skills and therapy training proved invaluable)
Practitioner: Narmada Keshav, a senior social worker and an accredited cognitive-behavioural therapist.
Field: Child and adolescent mental health services (Camhs).
Client: Adam*, a 12-year-old in foster care.
Case history: Adam’s mother is a heavy drug user who also has bipolar disorder. His father was physically violent towards him and his brother, Jon*. The siblings were removed and placed together with foster carers. The placement quickly broke down because of their challenging behaviour. The boys were then placed with separate foster carers.
Dilemma: Despite the neglect and abuse he suffered at the family home, Adam still wants to return to live with his mother.
Risk factor: Adam’s desire to live with his mother is stopping him from forming attachments with his new foster carers. The social worker needs to sensitively intervene to help Adam to understand he is unlikely to return to live with his mother. It is uncertain if a therapeutic approach is needed.
Outcome: Adam’s behaviour improves dramatically and he learns to adjust to life with his foster carers.
*Names have been changed
Story: Children entering foster care often find it difficult settling into their new homes, writes Mark Drinkwater. Adam*, a 12 year-old boy, was referred to Narmada Keshav, a senior social worker at a child and adolescent mental health service (Camhs) who specialises in working with looked after children.
When reading his case notes Keshav, who is also an accredited cognitive-behavioural therapist, discovered a disturbing backstory. “His mother had experienced domestic violence and she ended up in hospital several times. On one occasion she was in there with broken ribs,” she says. “Adam and his brother witnessed many of these horrific incidents. Adam also experienced physical abuse from his dad. He would hit him and bang his head against the wall. Adam was very scared of him.”
Adam and his brother, Jon*, were removed from their parents and were initially placed in foster care together. However, this arrangement was problematic and Keshav describes a worrying episode involving the siblings that led to Adam’s referral to child and adolescent mental health services: “Adam couldn’t settle in the first foster placement. The brothers were constantly fighting and the foster carers were not able to deal with them. Adam and his brother were so angry and scared at their separation that they trashed the foster carers’ house.”
Following this incident Adam was seen by a psychiatrist who diagnosed him as having a conduct disorder. The siblings were then transferred to separate foster placements.
When she started working with Adam, Keshav found sessions initially difficult because of his chaotic behaviour. “When I first met him I did think: ‘Gosh, where do I start?’ He was all over the place,” she says. “For the first few weeks Adam was dashing around whenever I met with him and throwing toys.”
At first, Adam was uncommunicative and found it difficult to concentrate and so his foster carer was included in these early sessions. Together they worked through issues in the foster home that were making Adam unhappy.
“This was a period of me getting to know him,” Keshav says. “I constantly engaged with his foster carer because I had to rely on her to tell me what was going on. At that point he was not able to verbalise what was troubling him because he has a mild learning difficulty.”
As weeks went by Adam gained in confidence and Keshav was able to address more personal issues troubling Adam without his carer present. Keshav found that while Adam had limited contact with his mother – seeing her for just a few hours every other month – he still cared for her deeply. This was at the heart of his difficulty with forming new attachments with his foster carers.
Through therapy, Keshav says she was able to help Adam understand his situation and that of his mother’s. “He constantly used to worry about his mum and desperately wanted to live with her. He was confused and did not understand his mother’s illness and did not understand why his dad would abuse him and his mum,” she says.
“Part of my therapeutic work as a Camhs worker was to help him understand that his mum was not well enough for him to go back and live with her, but that I could help him with dealing with his problems while he was in foster care.”
Keshav describes working with Adam through a number of therapeutic techniques: “We did exercises on his self-esteem. One of these exercises we did used stuffed toys through which he was able to externalise and explain what was troubling him. Through this he was able to engage in his past and his worry about his mother. We were able to address the traumas and the ongoing problems such as bedwetting and distressing dreams.”
Adam continued to see his brother; staying overnight with him once a fortnight. While this contact was important, it brought further problems for Adam because he perceived his younger brother to be receiving preferential treatment. For instance, Keshav explains that she had to work hard with Adam helping him understand why his brother might be allowed a mobile phone when he was not allowed one.
It’s been more than a year since the initial referral and Keshav is able to evaluate the impact of her work with Adam. Reflecting on her role she acknowledges that the combination of her social work background and her skills as a therapist enabled her to help Adam address both practical and therapeutic issues. She recognises that there is still much further to go, but that he has made huge progress. “He’s doing well. There are problems, but he’s much calmer now,” she says.
WEIGHING UP THE RISKS
Arguments for taking the risk
● Vital intervention Adam’s behavioural and emotional issues are hindering the success of his foster placement. Without an effective intervention this second placement is likely to break down.
● Therapeutic techniques The case is allocated to an experienced Camhs worker who can draw on her expertise in social work and therapeutic techniques. They are ideally placed to sensitively intervene.
● Range of techniques Adam is uncommunicative initially. The Camhs worker has a wide range of techniques that enable her to help Adam deal with his feelings.
Arguments against taking the risk
● Uncertainty over approach Adam has mild learning difficulties and it is uncertain that a therapeutic approach would benefit him.
● Conflict of interest The foster carer is involved in the early sessions. This could lead to the concerns of the foster carer taking precedence over the issues that are troubling Adam.
● Risk of dependency There is a risk that Adam could become dependent on the Camhs worker, which could prove problematic in the future.
By Patrick Ayre, senior social work lecturer at the University of Bedfordshire
The care plans devised for children like Adam and Jon sometimes seem to suggest their social workers expect a placement in a caring, predictable and nurturing environment such as a typical foster home will, in itself, rectify problems caused by traumatic and abusive experiences.
If only it were so simple. In reality, when children have experienced what Adam and Jon have, the challenges which they present are not merely relatively superficial reactive responses to their damaging home environments.
Rather, their problematic behaviour arises, at least in part, from fairly fundamental changes which have occurred in the functioning of their brains. Brain development is “activity-dependent” and every experience which a child has excites some neural circuits and leaves others alone. Neural circuits which are used repeatedly strengthen; those that are not used wither.
If children are regularly exposed to strong emotions such as fear or anxiety, the way in which their brains process emotion is radically transformed, to the extent that the processing tends to occur in a different part of the brain. Such problems may require specific therapeutic intervention, which may be intense and lengthy.
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This article is published in the 18 August 2011 edition of Community Care under the headline “Is therapy the real answer?”