Case notes
PRACTITIONER Steve
Roberts, director of Radical Services, a therapeutic service for
young people.
FIELD Residential
child care.
LOCATION Penrith,
Cumbria .
CLIENT Renata,* a
13-year-old girl with a history of serious self-harm.
CASE
HISTORY Renata had come to care provider Radical
Services in a state of crisis. She had been in care for eight years
and had a history of unsuccessful foster care and residential
placements. Her local authority was having difficulties placing her
because she frequently self-harmed. This behaviour was brought on
by anxiety, particularly when around other young people or in
stressful situations.
DILEMMA: Radical
Services has various residential settings in urban and rural
locations. A remote placement was available, which would have a
calming effect but was far from medical facilities.
RISK FACTOR If
Renata inflicted a serious injury on herself, medical services may
not be able to attend the remote location in time to help her.
OUTCOME With
support, Renata settled into the rural setting. After a period of
individuals who habitually self-harm commonly do so as a way of
coping with traumatic experiences, writes Mark Drinkwater. Steve
Roberts is director of Radical Services, an independent provider
working with young people with complex behavioural and emotional
difficulties.
When Renata came to Radical Services she was in a state of
crisis, having experienced repeated foster placement breakdowns.
Her self-harming was particularly severe. "The behaviour included
hitting and cutting herself," says Roberts. She was engaging in
extremely risky self-harm.
Radical Services has several single placement units suitable for
such crisis work. An initial assessment looked at what triggered
these situations. It was identified that part of the problem
stemmed from the stress of being around lots of other people. So, a
key issue in providing care for Renata was deciding where she would
be best placed. Keeping her in a populated area would have risked
escalating her anxiety and with that, more serious self-harm.
One potential residential unit was situated in a remote forest
setting, but was far from any other facilities. However, the risk
of placing her in this isolated location was that should she
sustain a serious injury she would be far from emergency
services.
Rural
placement
Over the period of a year, this rural placement seemed to
provide what Renata needed. Away from the anxiety-provoking
scenarios she responded well to the tranquillity of the remote
site.
Roberts feels that Radical Services' success with cases like
this is partly down to its use of the therapeutic model
Transactional Analysis, which underpins its work. He says that the
model emphasises an ethos that promotes respect for others and
values healthy communication. "It helps young people to question
their behaviour and staff to question and think about their
responses," says Roberts. "This really helps us to separate
behaviour from the person and take the heat out of the one-to-one
dynamic. It provides a basis for informing and reflecting upon our
practice."
After a successful 15 months in the remote placement, it was
time to move on to the next stage in Renata's development. Moving
back to an urban environment was a big step for her, but as Roberts
remarks: "You can't live in a forest forever." But there were risks
involved in moving her once more. Roberts explains that continuity
of staff was important in providing a consistent service for her,
so the whole team moved with her.
In the urban setting some of the intense self-harming behaviours
re-emerged. "She still has her old ways of coping with difficulties
- the self-harm - but she is increasingly able to verbalise her
problems and emotions and is now more likely to turn her anger
outwards rather than inwards."
Roberts acknowledges that at times working with young people
with complex difficulties can be "a slow process," but this case
has made significant progress. "There is still some way to go but
she is now talking about what she wants to be in the future which
is more hopeful than the bleak fatalistic outlook that she used to
hold for herself," says Roberts. "There will still be really
difficult times ahead but she now has some conscious sense of a
future."
More details of
Radical Services
Independent comment
John Diamond, chief executive, Mulberry Bush
Organisation - a charity that provides therapeutic residential care
for children
Radical Services has responded with genuine flexibility to meet
Renata's needs. Renata's life history is sadly typical of many
children in the care system who, due to early multiple trauma,
enact their experience through an inability to make relationships,
multiple placement breakdown, and in her case self-harm as
attachment-seeking behaviour.
The use of observation in the assessment process seems to have
identified critical traumatic triggers for Renata. The service has
responded with a placement to meet her psychological needs, rightly
putting these before concerns about geographical distance.
The approach seems to work because the staff team have a clear
underpinning theory base, which helps them orientate to the primary
task of meeting Renata's needs. We can assume that she also picks
up on this containing ethos, which supports her recovery.
The staff team stayed responsive and moved to the urban setting
with her. Although the return inevitably re-opened some of the
original wounds, she now has a better experience of caring
relationships, improved self-esteem, and the ability to convert
acting out into verbal communication.
Arguments for taking the risk
● Forest placement offered a calm space: Renata arrived
in a state of crisis. She needed a service that met her needs for a
calm environment. The forestry placement offered this.
● Common approach important: Consistency is important in
the therapeutic process. The use of a common approach, such as
Transactional Analysis, in a small, consistent care team provides
children with the focused care they need.
● Space to develop relationships: The time alone would
give Renata the space to develop better coping skills and help her
to form healthy relationships with support staff.
Arguments against taking the risk
● Too far from emergency services: There is no
guarantee that there would be less self-harm in the forestry
setting. If Renata engaged in serious self-harm, there would be a
danger that she will be too far from emergency medical
services.
● Resources: Providing high levels of support
is an expensive option at a time when resources are limited.
● Over-reliance on isolation: Even if the rural placement
was successful, it could make her reliant on the isolated setting
and prevent a successful return to an urban setting.
This article is published in the 25 June issue of
Community Care magazine under the heading Out of the forest
into the light