Introduction
This paper represents a personal view of the evolution of the Mulberry Bush School and Organisation. I will define three developmental stages, and within these some “core concepts” which, in my view, have enabled our services to evolve. I will illustrate these with case studies.
In October 2008, under the Registrar of Companies in England and Wales, the School was incorporated under the name the Mulberry Bush Organisation, to better represent the growing range of charitable services delivered from the School site.
We regard the “organisational DNA” of our 67 year history of the “lived experience” of residential work with traumatised children as the “heart-beat” of the charity. This experience continues to drive our work and service development. Our outreach, training, consultancy, family support services, and associated research, continue to reflect the core values, skills, and the theory and practice that has emerged from this legacy.
We are in the final stages of a seven year quantitative outcomes research project with the University College London, Institute of Education. Alongside this we are embarking on a complementary qualitative study with the University of East London. We now find ourselves involved in a range of research networks, and encouraging a culture of “practitioner based research”.
The Core Task
The Mulberry Bush School is a residential school and therapeutic community providing specialist integrated therapeutic care, treatment and education to traumatised children aged 5–13 and their families. Due to extreme anxiety inducing behaviours, stemming from severe social emotional, mental health and complex needs, the children are referred by Local Authorities from across the UK. Our aim is to re-integrate children back into an appropriate family, school and local community.
As a result of early years and complex trauma, the children struggle to make meaningful relationships and develop a sense of belonging to their birth or substitute families. Without an early intervention these mistrustful, aggressive, chaotic and confused behaviours will be re-enacted in later life. Our work aims to strengthen the child's relationship to their family and society, to break abusive cycles, and reduce the risk of offending.
We offer education in its broadest sense; experiences of living and learning together in groups offer a “re-education in relationships”.
Beginnings and Organic Growth; the “Open System” and the Primary Task
The evolution or organic growth of the Mulberry Bush School as an “open system” has several sources:
• The ability and foresight of successive generations of staff and trustees who have nurtured its development.
• A capacity by these groups to adapt to the ever-changing external social and economic situations, and,
• An ability by these groups to facilitate regenerative internal growth and change.
The schools founder, Barbara Dockar-Drysdale, described the growth of the school as:
more like a living organism than an institutional organization
(Dockar-Drysdale, Reference Dockar-Drysdale1993. Preface, p. xvi.)
The concept of an organisation as an “open system” implies an ability to adapt to its environment – to seek the optimum “conditions for growth”, to periodically review its own emotional health, and to continue to deliver the “primary task” of the enterprise:
an enterprise or institution can only survive through a continuous interchange of materials with its environment. There are the materials that the enterprise distinctively exists to process . . .the boundary across which these materials flow in and out both separates the enterprise from and links it with its environment. . . the transformation of intakes into outputs. (Miller, Reference Miller1993. pp. 10–11)
The primary task of providing care, treatment and education to children with severe social emotional and mental health needs is delivered through a “lived experience” in a reliable milieu, in which chaotic children can explore and internalise safe relationships.
This difficult and demanding work requires a reflective culture, created through close collaborative team work: Regular reflective group forums, training, including our Foundation Degree in “therapeutic work with children and young people” support this work enabling staff to be attuned to the thoughts, feelings, behaviours, and relationships that exist between the children and adults across the community. Over time this containing and nurturing experience supports children to grow emotionally so they can negotiate and make improved use of social relationships.
Ongoing Evolution: Strategy and the Environment
Charles Darwin evidenced that it is not necessarily the physically strongest, nor the most intelligent of the species that survive, but the one most responsive to adaptation and change. I like to think this concept can be applied to the evolution and adaptation of the Mulberry Bush to its environment. The word “strategy” implies this adaptation: how change is thought about, and how the associated anxieties are acknowledged and then modified into appropriate planning. This has been the foundation of our strategy as a dynamic process.
In natural disasters such as the recent Nepalese earthquake, the environment can be terribly destructive, but so too can be the absence of a well-managed aid strategy. A combination of natural disaster and poorly managed relief aid compounds the risk of further fatalities, homelessness, disease and dislocation from vital resources.
In the same way, the layering of environmental risk factors associated with childhood trauma can lead to a lack of attachment and poor outcomes for children. Risk factors that diminish resilience include: family breakdown, parental drug addiction, major losses such as bereavement, neglect, sexual and physical abuse and domestic violence. These factors can become co-morbid and compound to decrease the chances of the child's successful adaptation to his or her family, home, school and community environment.
the child exposed to chaotic or threatening caregiving develops a sensitized stress-response system that affects arousal, emotional regulation, behavioural reactivity, and even cardiovascular regulation. These children are at risk for stress- induced neuropsychiatric problems in later life. (Perry, & Pollard, Reference Perry and Pollard1998. p. 40)
Core Concept 1: Community as Task
The children who are referred to the Mulberry Bush are some of the most emotionally damaged in the UK, and so require a set of integrated interventions that address their needs:
• Therapeutic work- the opportunity to experience caring and nurturing relationships.
• Educational work- teaching that imparts skills and knowledge.
• Outreach work to the child's family or other home setting.
• A secure and safe environment.
• Engagement with a community as a task; i.e., learning to live with and collaborate with others.
Of this set of needs, the final one is the most important; the children struggle to be able to learn to live within a group or community, in appropriate relationships with others.
Learning to “do” community is therefore the essential social task on which the other kinds of learning ultimately depend. Our experience tells us, when working with emotionally fragile children, it is the ability of committed and well-supported staff who enable the children to learn to live in and as a group, that creates real stability of placement.
In this work the “collective mind” of staff teams is essential. On a daily basis they assess and manage the prevailing group dynamic, and maintain or change it through the use of attuned relationships. The development of such a clinical sensibility allows staff to think about, tolerate and modify the emotional pain. Our aim as a therapeutic community is to create a planned environment that holds the child in mind at the heart of the system. When this experience is internalised by the child, we achieve good outcomes. In this way, we provide the following “protective factors” that strengthen resilience:
• Someone to confide in: through the provision of empathic relationships with care workers, teachers and through psychotherapeutic interventions.
• Opportunities to demonstrate success or competence in some area of life. We support children to become successful learners and to make use of learnt skill and knowledge.
• A containing and nurturing environment: Research into resilience shows that overcoming adversity once may make it more likely that one will overcome it a second time, in this sense “survival aids survival”.
• Developing resilience. Being able to develop a sustainable and coherent sense of self. Our aim is to facilitate the emotional development of children from “unintegrated” and fragmented states of mind, to a capacity for “thinking and feeling” through the growth of the personality.
A therapeutic environment requires clear roles and boundaries. Such a framework creates the conditions for empathic containment and nurture, which in turn facilitates emotional growth and learning, leading to good outcomes.
The following section explores how our early history has provided a strong and enduring foundation for this work.
Developmental Stage 1: Therapy in Child Care: The Foundation of Therapeutic Work at the School
During World War 2, Barbara Dockar-Drysdale and her family shared the original farmhouse with children placed with them to escape the London blitz during the national evacuation campaign. She soon experienced the challenging behaviours of a number of them. After the war via monthly clinical consultations with Dr. Donald Winnicott, and a psychoanalytic training, she developed the residential treatment methodology that she later named “the provision of primary experience” (Reference Dockar-Drysdale1990). Across the 1950's and 1960's she conceptualised this work, and later published it in her books “Therapy in Child Care” (1968) and “Consultation in Child Care” (1973).
In 1948 her work achieved School status from the Department for Education, as a cross between a special school and child guidance clinic. The “holding environment” then consisted of a small community of adults who provided the children with positive experiences through the daily routines. Through regular discussions the staff developed more focussed therapeutic skills: e.g., paying attention to the symbolic aspects of communication, and harnessing the therapeutic potential of play. Each interaction could be used therapeutically in service to the core task of building relationships.
Core Concept 2: “The Provision of Primary Experience”
Dockar-Drysdale's primary experience seems to be an amalgam of the Winnicott concepts of ‘primary home experiences’ and ‘primary maternal preoccupation’. The term encapsulates what Dockar-Drysdale came to see as the essential element in therapy for children who had missed out on that early maternal provision. . . .her view of primary provision could be summed up by saying that it was a matter of the caring adult having to feel and act like a mother with her new born baby, and with the same preoccupation and sense of vulnerability. (Reeves, Reference Reeves2002. p. 10)
Within this concept of “the provision of primary experience” Dockar-Drysdale defined different syndromes of deprivation, and formulated treatment approaches to these:
Dockar-Drysdale has done her most important work in seeking to explain the nature and needs of the ‘frozen’ or psychopathic child. The emotionally deprived child is seen as ‘pre-neurotic’ since the child has to exist as an individual before neurotic defences can form. The extent to which there has been traumatic interruption of the ‘primary experience’ decides the form of the disturbance. A child separated at this primitive stage is therefore, in a perpetual state of defence against the hostile ‘outer world’ into which he has been jettisoned inadequately prepared. (Bridgeland, Reference Bridgeland1971. p. 274)
In the early day of the school as a therapeutic milieu, staff provided “close in” experiences of containing and nurturing routines and robust behaviour management. Close dependency on an adult was supported, and in the case of the “frozen child” a localised regression to the “point of failure” was therapeutically managed. Sometimes a symbolic adaptation, termed a “special thing,” was introduced. This allowed the child an experience of primary adaptation to need, an experience of close bonding with a primary carer:
This symbolic adaptation would often take the form of the child's “focal therapist” providing a food with a primary connotation being chosen by the child e.g., a rusk with warm milk. They found that the provision improved the child's sense of security, reduced delinquency (stealing as self-provision to “fill up”), and the localised time seemed to help children cope with their feelings of envy when having to share with others in the group care setting.
This “attachment” model of meeting need, with attention to symbolic communication, still underpins our work. In Dockar-Drysdale's view, for chaotic “unintegrated” children the traditional “psychoanalytic hour” was not enough, they required a total environment in which therapeutic interactions could take place within the daily routines of child care, she did not place the primacy of therapy as being outside of daily child care routines, hence the development of the concept and methods now known as “therapeutic child care.”
Further Reflections: Bringing the Past and Present together
In 1958, Dockar -Drysdale wrote her paper “the residential treatment of frozen children”. In this, she describes experiences and offers clinical vignettes of working with some of the most “unintegrated” children. She describes these children as “emotionally frozen” at the “point of failure” or trauma.
Neuroscientific research now tells us how the brain of the human baby physically grows, and synapses connect, as a result of being in a loving relationship, nurtured and stimulated by the mother or primary carer. Conversely, if the baby experiences ongoing neglect and abuse, the evolving brain is overwhelmed by stress, releasing adrenalin and the stress hormone cortisol. The impact of trauma, the flooding of the brain by cortisol and the undigestible traumatic experience, does as Dockar-Drysdale proposed, freeze or arrest this developmental process, leaving the child unable to regulate their states of mind, and adopting states of hyper arousal as a defence to protect them from the perceived hostile environment.
Developmental Stage 2: Using Groups and the Environment as a Therapeutic Medium
By the start of the 1990’s, due to the implementation of the British governments “Children's Act” (1989), our Trustees recognised the need to modernise the school site. From 1995–2001 through a successful fundraising campaign the site was re-developed, and the children moved to inhabit the four newly built households and education area. This achieved our strategy to develop a new therapeutic model of group living within a purposely planned environment, to improve the therapeutic experience for children. The experience of inhabiting a purpose built site led to a creative re-appraisal and exploration of our work.
Core Concept 3: Developing “Emotional Distance Regulation”
The conditions were now created to better meet individual need within household and class groups, and this work could now be thought about within the context of the “large group” of the school community. This work has evolved, and now the application and interplay of these different group mediums offers each child a chance to learn to live in and as part of a group; a “re-education in relationships”, through which children can begin to gain a more coherent sense of self.
During this period of change we also experienced the “acting out” or regressive behaviours of children as being the primary “emotional currency,” and in response to this an improved understanding of “behaviour as communication” became the collective task. We realised that the transference material, projected into staff, was almost too readily available. Conversely, we recognised that we also needed to think about how our own unconscious (and infantile) needs are reactivated within the work, and try to reduce these being acted out in the workplace
Case Study 1: “Billy”
Some years ago “Billy” (anonymised name) aged six was referred to the school. On his arrival some staff members talked about their warm, sentimental feelings of working with such a young child. Billy played into these relationships, which focussed on enlisting a positive transference from the staff. When Billy started to act out his abusive past through extreme unprovoked aggression towards the same staff, they struggled with their now conflicting feelings of hatred and anger towards him, and realised they had become involved in a complex enmeshed relationship.
To better understand this risk of enmeshment, reflective groups were established to improve the team's ability to think about this work. Group discussion and sharing experiences and observations led to an improved understanding of the complex emotional material we were working with. Our aim was to become better reflective practitioners, and create a trauma informed organisation. Staff teams now use “reflective spaces” to think about their own feelings, and they have developed a keener use of their counter-transference as they engage as participant observers alongside the children. Over time this “emotional distance regulation” has enabled the development of more appropriately bounded relationships, better thinking spaces, and an improved emotional economy of relating.
The business of setting up the therapeutic system is, therefore, the business of setting up structures to reduce the effect of the staff unconscious on the staff/child relationship and to maximise the chance of detecting the effect of the child's inner world on the system.
(Stokoe, Reference Stokoe, Ward, Kasinski, Pooley and Worthington2003. p. 83)
Currently, our multi-disciplinary “Treatment Teams” (Figure 1) use the Integrated Treatment Plan to track each child's social-emotional growth and educational attainment, across the duration of their placement.
The treatment team model.
Notes
• The Treatment Team is our way of ensuring thinking about each child is fully integrated.
• The team aims to recognise the different ways children present themselves to people and in different situations.
• The members look to the “whole child” when assessing and planning.
• Household Managers implement plans and ensure records are kept and updated.
• Additional people may be asked to join a Treatment Team to offer a different or specialist perspective e.g., the school nurse.
Developmental Stage 3: Reaching Out to the Wider Community
Since 2007 we have focused on taking our services out to the wider community. Our core aim to re-integrate children back into an appropriate family and school has influenced this work. The development of the Therapies and Networks Team and our “MBOX Teaching School” Outreach team, have enabled this “exporting” or reaching out with our core values, expertise and skills to families, mainstream schools, and other organisations working with children.
Core Concept 4: Working with Families: The Therapies and Networks Team
In 2011, we developed the multi-disciplinary “Therapies and Networks Team” comprising of therapists and family network practitioners. The team has extended our commitment to working with the families of referred children, in recognition of developing a more systemic understanding of the inseparable nature of the child's difficulties in relation to their family network, and to reduce the burden of responsibility on the child for carrying emotional disturbance on behalf of the family.
The team ensures a “Partnership Plan” is in place to meet the holistic needs of each family. For some parents and carers the team can offer counselling or family therapy, so there is a better fit at the point of re-integration, between the emotional maturation of the child and the family dynamic.
Many of our families have felt repeatedly blamed by the network of professionals with which they have inevitably been involved before the children reach us. They often arrive feeling wary and defensive at the suggestion of family work. When we think about this concept of families sharing the responsibility for change with the child, we are not suggesting that families are to blame. Indeed, we are acutely aware that in many cases, particularly where adoptive families are concerned, parents have worked tirelessly to enable family life to succeed under very challenging circumstances, and sometimes the culmination of this work has led to the child's arrival at the Mulberry Bush”. (Browner, & Onions, Reference Browner and Onions2014. p. 4)
Case Study 2: The Mulberry Bush as a Community Outreach Service
Anna (anonymised name) was born in November 2005. Her mother had experienced early neglect and abuse, and as a result of this suffered bouts of severe depression, and she regularly used alcohol and drugs when she was feeling down. She struggled to look after Anna, who also experienced inconsistent care throughout her early years. Anna was often neglected, and consequently she was unable to develop a healthy attachment to her mother. She became very mistrustful, and developed severe emotional and behavioural difficulties; enuresis, encopresis, biting and hitting her mother, and refusing food.
These behaviours increased during her mother's periods of depression. Eventually neighbours expressed concern about Anna's dishevelled appearance, and the family received an intervention from the local social services department. At age 6, Anna was accommodated by the local authority and placed with foster carers. She started to attend a nearby school for children with emotional and behavioural difficulties. However, mum received little support. The foster carers found Anna's relentless destructive behaviours too difficult to manage. After one month the placement broke down. Anna was placed with new foster carers, but this placement quickly became unstable. During this time, her school was placed in “special measures”, as it was unable to contain and meet the diverse needs of its pupils.
At age 7, Anna was referred to the Mulberry Bush School. She joined our intake household, where a dedicated team of staff provided consistent routines and structures. The team worked closely with teachers from the “foundation stage” in our school, and with our therapists and family support workers. Anna started to experience adults who could manage her behavioural difficulties, engage her in education, and provide her with caring and meaningful experiences. After one year, for the first time, she began to develop basic trust in adults who could understand and tolerate her chaotic behaviours and strong feelings.
“MBOX Teaching School”: Supporting Anna's School
Through working in partnership with the referring local authority, the Mulberry Bush was also able to offer its expertise to Anna's school. Outreach workers from our MBOX Teaching School project were able to visit the school on a weekly basis. The project encouraged the teachers to reflect on their practice and develop a shared understanding of the causes of emotional, social and behavioural difficulties using a collaborative problem solving approach. Over time, the Head confirmed that the project had helped to develop a more cohesive “whole school” atmosphere, with staff improving their ability in sharing and supporting each other. The provision for pupils who displayed challenging behaviour, and the assessments of those pupils causing most concern also showed significantly high rates of improvement.
Working with Anna's Mother
Out of our initial assessment of Anna and her mother's needs, the “Therapies and Networks Team”, identified that unless Anna's mother also experienced an appropriate therapeutic intervention, she would not be able to grow emotionally and be able to have Anna back with her. Her mother has accepted fortnightly counselling from a Mulberry Bush family support worker. She now regards this as a “lifeline” and is making good progress in managing her lifestyle. She also attends regular residential weekends with other mums at the School. These are designed to help develop her parenting skills, and her relationship to Anna.
Conclusion
Since our beginnings in 1948, the Mulberry Bush School and latterly the organisation, has continued to keep meeting the needs of troubled children and their families at the heart of its charitable mission.
In this paper, I have explored how from the inheritance of the “lived experience” of our 67 year history, and through ongoing innovation and adaptation, our current model of therapeutic residential work and associated outreach services have emerged.
