Building and maintaining the therapeutic structure, and some thoughts on the consultant’s role.

John Burton. July 2018

In The Handbook of Residential Care
(Routledge 1993)
I wrote a chapter called “Creating helpful organisation”. It
covered buildings, furnishings and decoration, using money, boundaries, public
and private space, kitchens, bathrooms and lavatories, food and catering, team
and community meetings, supervision, staff support groups, training and
development, rotas, routines and habits, smoking, and rituals and celebrations.
In addition there were of course such essentials as bedtimes, mealtimes and
getting up. In my current consultancy work with children’s homes I now call
“helpful organisation” therapeutic structure; in other words the organisation’s
fabric, culture and processes that are needed to support and contain
therapeutic work.

The next chapter in the book dealt with “hindering organisation” and I
could have called that “unhelpful organisation” or anti-therapeutic structure.
I meant the all too common potential for bureaucratic and authoritarian
management to divert a care home – of any sort – from its core purpose of care
by inserting institutional defences against anxiety between the therapeutic
workers and their task of healing through relationships.

Over the years I have seen much good therapeutic work done at all
levels and in many homes, but the structure holding this work is often fragile
and temporary. A home will have a good run for a while and then things begin to
fall apart, and have to be rebuilt all over again. Good staff leave; discipline
around the use of the office slips; teams fracture; bedtimes become chaotic;
staff get tired and grossly overworked; morale falters; the home looks a mess;
the residents are in charge; keys get lost and stolen; crockery, furniture and
windows get broken; people start eating and drinking from plastic and paper;
meetings are poorly attended; staff take refuge in the office where eggs are
kept; community meetings are forgotten and handovers don’t happen; sanctions
are imposed and found to be useless; placements dry up; people become more
concerned about parking their cars  or
taking a smoking break than preparing breakfast; notices don’t mean anything;
children run away; day staff blame night staff and vice versa; there are
“strong” teams and “weak” teams; supervision doesn’t happen; staff are sick . .
. and so on. All of those don’t often, if ever, happen all at the same time,
but they do happen and they are all signs of a failure to build and maintain a
reliable therapeutic structure.

Children’s homes (and all residential care homes) exist in their
environment – the managing organisation, the legal and regulatory regime, their
wider social and political  context, all of
which have a part to play in a reliable therapeutic structure and frequently
fail to provide it. So, there is only so much that a children’s home can do to
build and maintain a therapeutic structure if the structures around it let it
down. 

Consultancy

It’s been my practice to write notes to the manager when I get home in
the evening after spending a day with a home. The manager then distributes
these notes to the team. Getting to the home as early as I can in the morning,
I usually say hello to at least some of the children and may sometimes be with
the team when they are handing over. Later I attend the team meeting, have
lunch with the team and any residents who are still in the house, and then in
the afternoon we have a whole team consultancy session. Finally I meet with the
home’s manager. It’s a packed day for me during which I get a sense of the
whole home and how it is working. While I may be able to offer some useful
thoughts about the children, they are not my focus. I work with the team and the
manager – and, of course, the whole home as a “psycho-social” system.

Periodically I work with the directors of the provider organisation,
and have workshops with the whole senior team. They are responsible for the
overall therapeutic structure of the whole organisation which needs to be
designed, developed and maintained to be in tune with the core task of
therapeutic child care. (The same principles apply to all therapeutic
residential care for all ages.)

The therapeutic structure is a whole construction made up of many parts
which are all connected. The strength or weakness of any one part affects all
the other parts. There are foundation stones, keystones and cornerstones in
this construction; without them the therapeutic work that they support, hold
and contain will crumble and fall.

Recently, having worked with an organisation for several years, I
realised that I had become part of the system in a way that was blocking
change. I was following the same pattern and so were the homes. What had been
helpful and challenging observations two, three and even four years ago, had
now become what everyone was used to. Countless times I had fed back to staff
and managers (at all levels) when the structure was crumbling or had been
insufficiently developed in the first place, but we were discussing the same
issues over and over again. (Of course there are perennial issues in
residential care, but a home should become more alive to those deep underlying
anxieties, more adept at identifying them for themselves, and resistant to
reaching for stop-gap “solutions”. Locking doors is a typical one that arose
only yesterday.) And their consultant should be helping them to do it for
themselves rather than holding on to being ineffectually perceptive. So, I
repeatedly circulated notes and articles about such matters as the rota and the
budget, and while I acknowledge that they may have been read and discussed, I
still didn’t see that deep change had taken place. And, of course, I had
highlighted failures in the structure in my consultancy notes and in discussion
with teams and managers. I was finding that I could take this horse to water,
but try as I might, I couldn’t make the good creature drink! (And these were
good therapeutic homes in a thoughtful, honest and well motivated organisation.
Fly-by-night, quick-buck organisations don’t go to the trouble and expense of
engaging a consultant to do this sort of work.)

Our resistance to structure

As residential workers (I’m proud to call myself one) our ambivalence
about structure is deep seated. We know the value of reliable structure yet we
resist it. Structure seems to contradict the creative and liberating potential
of therapeutic relationships. Nor do we want to face the difficulty of
challenging ourselves or our colleagues when we fail to work to a structure we
have all agreed to. When you work so closely and are so dependent on good
personal relationships, it is tempting not to question your colleagues but to
turn a blind eye to avoidance of duty. We weave ourselves a tangled web of
little collusions. Collusion breeds collusion, and the guilt is silencing.
People really do mean it when they resolve to adhere to structures, and it is a
hard thing to say “You failed” to a close colleague. Poor timekeeping is a
common example of this avoidance. Rarely do we say to each other, “You’re late
and that’s not good enough for the children, the team or for me. I won’t put up
with it.”

The lure of heroic work

Some experienced workers can manage difficult situations by using
personal tricks of management while ignoring agreed structures; thereby, they
undermine the therapeutic structure and their colleagues’ authority, and make
themselves indispensable. With a background of creating personal authority in
unstructured settings, and a remarkably intuitive feel for the emotional
atmosphere of a children’s home, some managers, without meaning to, maintain
their heroic and charismatic aura, and they can even unconsciously collude with
creating incidents which demand their emergency intervention.  

The temptation to be a soothsayer

A parallel process may entangle and seduce the consultant, especially
one (like me) who has experienced the work at first hand. We look back on our
own practice with rose-tinted spectacles, forgetting that we too colluded with
resisting and undermining the therapeutic structure while telling everyone else
how vital it is to build and maintain it.

In the short term it may be satisfying to draw the team’s attention to
your prediction of two months ago that has now turned out to be spot on; in the
longer run you have to ask yourself how useful – or, indeed, usable – was that
prediction? When we make predictions – even dire ones – we have some investment
in it coming true, so that we can say “I told you so.” It may make the
consultant feel and look clever, but the role of the consultant is not to be a
soothsayer with mysterious powers of perception and prediction, but to help
people to internalise a lively and practical awareness of what’s happening and
a theoretical conception with which to understand it.

_______________

In writing this article and re-reading it just now, I see that I have
used the soothsayer ploy in the opening paragraph: “I told you all of this 25
years ago!” So, perhaps it is legitimate to start a consultancy engagement by
demonstrating that you are capable of perception and prediction, that you can
provide a theoretical framework within which to understand what’s happening,
and that you can communicate all this in a useful way. However, I’ve argued at
the end of the piece that a consultant should move the engagement on from this
stage to helping the team or organisation to internalise consultative
perception and theory.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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