The Other 23 Hours

Child Care Work with Emotionally Disturbed Children in a Therapeutic Milieu

Larry Brendtro

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351477789
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

Among other revolutionary developments of today's world is the so-called "knowledge explosion". So much is being written so fast about so many things that it is becoming well-nigh ir--retrievable. One consequently can never be sure that he knows what there is to know about many kinds of phenomena or types of problems existing in the modern world due to the chance that something exists in written form that simply cannot be found, so bulky is the load of literature. The common idea that only the sick child, and never the well, needs special emotional supports and helps from the adult is simply an error. For the well child is not immune from pile-ups of severe emotional intensity when overwhelmed by confusion and conflicts from within. Certainly, the normal kid can be ex--pected to handle such crises either from within or without better than his sick peer on the average, but that does not mean always; and the critical issue for the well child is: is he ready at the time they hit? If not, he needs, quite unmistakably, emotional first aid from the adult - parent, teacher, camp counsellor (or what have you) - who is in charge of his life at that moment. The reader will find that what the authors describe in The Other 23 Hours as the everyday requirement diet, as far as child handling is concerned for their disturbed children, is transferable to the normal crises of normal child--hood.

I
Understanding the Nature of a Therapeutic Milieu

Albert E. Trieschman

I should like to find out, not only what milieu is and how it operates, but also how we can describe it, how we influence it, and by what actions of all involved it is, in turn, created or molded. At the moment I am convinced of only one thing for sure—we all have quite a way to go to achieve either of these tasks ( Redl, 1966, p. 94).

These problems face us nearly a decade after Redl posed them and more than four decades after professional work with children began citing the child's living situation as a therapeutic influence.

This chapter deals with these problems by presenting one kind of framework for understanding and utilizing a milieu as a therapeutic tool. Our notion is that the actions of adults with children and the adults' control of the environment can be coordinated to improve children's lives. Our framework is constructed for the adults who people a milieu: child-care workers, houseparents, counselors, nurses, social workers, group workers, psychologists, and psychiatrists. It is meant for all the adults who deal with children, or plan for children's living situations, whether they deal directly or supervise or advise those who do deal directly. Our major concern is the 23 hours outside the psychotherapy session—because that is when and where most of the milieu is.

Unfortunately we fall far short of complete answers to Redl's questions. Our look at the milieu is like a sea chart and some word pictures. It is unable to capture fully either the beauty or the turbulence of the milieu's many moods, and is hardly adequate to guarantee you will be a good sailor in that sea. If you grasp some of the excitement and power of milieu treatment and feel better equipped to participate in it, we will have succeeded.

The word milieu is our first hurdle. It is troublesome to pronounce and awkward to spell. What is it? Without being profound, let us settle on what we are talking about. We are describing a group living situation for children, specifically for children with emotional problems, children who must live away from home and whose lives are full of crises.¹ We are focusing on events that occur and processes that exist in such a setting. Moreover, we are thinking in terms of people using these events and processes as an effective tool to help children. It is our bias that much of what we say applies to child-rearing is general.

The chapter is divided into three sections. First, we deal briefly with the history of milieu treatment and the place of our notions of the milieu. Second, we consider the concept of the ego and its usefulness in conceptualizing the milieu's work of altering or changing behavior. Third, we consider some learning processes that go on between adults and children and some teaching forms through which adult actions and arrangements can occur in a milieu.

The Concept of Milieu

The daily events in a group-living situation may be viewed as foreground or background. The events and interactions of the day may be thought of merely as time-fillers between psychotherapy sessions, or only as providers of life necessities such as eating, sleeping, and recreation. Or—and this is our preference—the milieu can be thought of as the major impact that the institution has on the child. Whether as a time-filler or as a major therapeutic tool, a milieu exists in every groupliving situation.

In recent years, every children’s institution has claimed that they have a “therapeutic milieu,” implying that they paid special attention to the therapeutic use of daily events. That claim is only possible since August Aichhom’s work in the 1920’s. He first called attention to the planned use of the milieu as a therapeutic tool. Aichhom (1955) wrote of the application of psychoanalytic ideas to the treatment of delinquents. Among many other things, he dealt with the organization of his training school, commented on grouping problems, and pointed out the significance of particular work assignments. He emphasized tailoring the environment to individual needs, as understood through psychoanalytic insights into individual children.

More recently the problem of milieu has been approached from a sociological viewpoint. The work of Stanton and Schwartz (1954), Erving Goffman (1961), and the Cummings (Cummings and Cummings, 1963), all with adults, has emphasized the importance of the social system that surrounds the patients. In between the vantage points of individual psychological and system sociological theory has come the classic descriptions that blend processes, events, and individual case episodes—provided by Redl and Wineman (1957) at Pioneer House, and Bettelheim and Sylvester (Bettelheim, 1949, 1955; Bettelheim and Sylvester, 1948, 1949) at the Orthogenic School. To all of these pioneers we are much indebted. They have taught us that the milieu can be a powerful therapeutic tool and have variously shown how individual psychological dynamics and the social system can be combined to manage and to change lives. Our contribution is dependent on their work.

We have not composed a new psychological or sociological theory. Rather, we have attempted to present a loose phenomenology of the milieu as a teaching tool. What goes on daily between children and adults is seen as an opportunity for therapeutic education or re-education of the child. The practitioners of the art of child care are our primary audience. They are the main teachers in a child-rearing milieu. Our assumption is that the rigidity, punitiveness, or over-permissiveness of some child-caring situations more often comes out of staff desperation than out of staff pathology or “meanness.” Our hope is that better understanding of what is going on in the milieu, some sense of alternatives available to adults, and a means of communicating to fellow staff about what is going on will reduce that desperation. Hopefully, our ideas are stated broadly enough to keep the attention of readers from a variety of milieu situations: hospital wards, cottage systems, specialized schools, group homes and residential treatment centers.

Behavior and Ego Ideas

Children are placed in a therapeutic milieu so that we can help them change their behavior. We are using the term “behavior” in its broadest connotations and intend it to include intellectual and emotional aspects of childhood as well as actions or observable behavior. The changes we have in mind are not narrowly conceived as correction and even include growth and maturation. Without getting into the complications of diagnostic labels (mostly broad statements of what needs changing about the child), we can agree on some major categories of desirable change. We would like to help a child stop or diminish deviant, dangerous, age-inappropriate behavior. We would like to help him start or develop adaptive, productive, age-appropriate behavior. In short, we need to help the child to alter his behavior. The alternatives we teach are a complex and various pattern involving the interruption of deviance or “sickness” and the substitution of age-appropriate, productive, coping skills. Of course, this should not be thought of as a simple progression from bad to good, to better, to best behavior. A child’s development should not be seen as a series of golden means in smooth ascendance to maturity: neat but not so neat as to be compulsive, has friends but can deal with solitude, asserts his rights but is not too aggressive, happy but can deal with sadness, etc. A series of twists and turns, ups and downs, extremes in one direction or another would be more appropriate descriptions. Add to that the complication that change for the better often leaves a child uncomfortable between old ways and not yet fully mastered new ways, and you can see all will not be smooth in this business of helping children change.

In what follows, we will explore the concept of alternative behavior, and consider some categories for identifying and communicating about behavior problems. Then we will seek guidelines for our teaching of alternatives from a developmental view of the child’s ego and from a view of what daily events require of the ego. Finally, we will look for the areas of support to ego teaching that are available in the milieu.

We hope these sections will present both a means of satisfying children’s needs and a means of helping children develop new competence to deal with life and learning. We are interested in curing mental illness, in serving children’s needs, and in undoing the crippling effects of the past. But we are equally—perhaps more—interested in challenging children with the adventure of life, in promoting improved capacity to deal with the struggles of human existence, and in anticipating the opportunities of the future. The adults in a milieu are not just the suppliers of psychological medicine to empty, sick children; they are also the knowledged companions of children in an adventure full of challenges, obstacles, and opportunities. By combining giving something to and expecting something of children, we teach the lessons that promote love and competence.

The Concept of Alternative Behavior

For a moment let us concentrate on what we see, feel, and hear from a child and our need to change this behavior.

Johnny came out to mv car again today. As soon as I got out he pounded me in the middle of the back. He’s been doing this a lot recently). It really hurts. I was puzzled because he always seems glad to see me.

Clearly, some alternative form of greeting is needed. But first we have to stop the pounding. To stop the pounding may be simply a matter of shouting at the child, refusing him friendliness, or actually punishing him. We hesitate to do those things because we value the growing positive relationship with the child. We could just tell him we don’t like pounding, but that may prolong our martyrdom if he doesn’t get the message. We should note here that stopping one piece of behavior and substituting nothing for it is a very difficult task for both the child-care worker and for the child. What could we substitute in the greeting situation?

This particular child-care worker told the child he did not like the pounding and decided on substituting handshaking, an act that he carefully practiced with Johnny. Johnny’s need for physical contact in order to express his growing sense of trust was a hungry thing. The handshaking soon developed into counselor-child invented secret handshakes and later into elaborate hand-puppet games that were real affect dramas.

Without laboring the point, it is clear that stopping the pounding was facilitated by substituting another piece of behavior that provided similar satisfaction and was more acceptable, age-appropriate behavior. It is important to note that in developing this piece of alternative behavior, three activities were involved: interruption of behavior (don’t pound me), substitution of behavior (handshaking), and invention of behavior (secret handshakes, hand puppet game).

Interruption of Behavior. Some behavior cannot be allowed to continue because it is dangerous to the child or adult involved, is disruptive to group living, or is destructive of the plant and equipment needed to help children. Adults will need to tell the child to stop such behavior and at times will have to stop the child. It is important both to stop some behavior for the child and to expect him to stop some behavior himself. This is obvious and need not keep us long. Basic honesty requires that you not offer an option to stop or continue (will you please, etc.) if you intend no option. Helping a child make choices is one significant teaching area, but not if you clutter it with phony choices.

Much behavior is not of the sort that clearly needs stopping. Some behavior is to be encouraged, other behavior just permitted, some ignored, and some prevented by the adult's control of circumstances.² We focus here on those all too frequent times when interruption is required, because they make our point clearly.³ That is, that “control” of a child’s behavior is a teaching opportunity; stopping something is an opportunity for behavior alteration.

Substitution of Behavior. The interruption of behavior often provides an opportunity for teaching a substitute piece of behavior. As with the handshaking, substitution refers to the teaching of some action (idea or feeling) the child already “knows” but does not use in the situation you are dealing with.

The choice of the substitute activity should be guided by some criteria—its fit with your best understanding of the child’s intent, its social acceptability and age-appropriateness, and its capacity to diminish the alienation and self-defeat of the original behavior.

Skilled child-care workers get children to substitute mutual balance or leaning games for “hanging all over” adults. They may teach a child a way to ask to join a game instead of stealing the ball. They may bring a book or puzzle to an isolated child—in effect teaching, by substitution, some constructive uses of solitude.

Invention of Behavior. Invention refers to the teaching of alternative behavior that is not already a part of the child’s repertory of actions (feeling, idea). Often it is the most advanced form of alternative behavior teaching. It usually involves a close adult-child relationship, with a considerable amount of identification of the child with the counselor. Identification is meant to signify the child’s copying of a competent model whom he admires.⁴ In this situation the adult is sometimes able to design with the child a new piece of behavior. Substitution implies some “newness,” in that an old piece of behavior is used in a new way. Invention involves “new” behavior to the child. The secret handshaking and the puppet play that Johnny and his counselor did were new activities to this boy.

Some teaching of alternative behavior by invention is involved in everyday occurrences such as playing a new game. The regulation and miniaturizing of aggressive play that occurs in board games like “Combat” is a case in point. Though some of the same basic instincts or impulses of the child may be involved in physical fighting and the board game, the invented behavior of the game is “new” in our sense of the word.⁵ Teaching a child appropriate modesty instead of hiding at shower time, teaching a child sports expressions (like “kill the ball” or “smear the ball carrier”) that are more socially acceptable angry noises, or encouraging a child to criticize a director so he will learn that he won’t be destroyed for doing so—these are a few examples of “inventions” as a form of alternative behavior teaching.

There are many subtle versions of behavior inventions. One favorite “lesson” of a very skilled child-care worker was the teaching of “manners” and “cliched conversational forms.” Some shy children avoid social interaction by “putting off” the other person (adult or child) with bizarre antics (grimaces, hiding, postures, etc.). After both adult and child recognized the intent of the behavior, this counselor would teach such children more usual and acceptable forms of I-don’t-want-to- interact kind of interaction. “Hi, nice weather, see you around, fine, okay, nice to meet you, thank you, please, goodbye, you’re welcome” can all serve to end or to avoid conversation, without needing to resort to scaring people off. In some respects it is the shy child who needs such forms and manners more than the bouncy, outgoing child who often charms people despite his acting out or aggressiveness. That such invented alternative behavior can lead to more basic changes—such as discovering it can be pleasant to interact with people—is incidental to our categories. At the least the child will know some useful behavior to alleviate his present shyness and will be prepared with behavior that will be useful if (when) he comes to desire more involvement with people.

The whole area of teaching a child how to cope with sadness is another possible subtlety. It is typical for disturbed children to be angry when it would be more appropriate to be sad. Helping a child gain competence to deal with loss—even in small matters such as “no mail today” or a broken toy—can be a considerable down payment on dealing with his life depressing issues. When we model expressions of sadness, when we help a child seek replacements, when we help him to forget “that trouble” and go on to something else, we are inventing (sometimes substituting) alternative behavior that is an essential part of human equipment. It is interesting to note that we are now talking about helping a child to learn the behavioral skills to do what psychotherapists refer to as “the work of mourning” ( Trieschman and Levine, 1968). And children separated from families have much mourning work to do. It is a truism that the “children who hate” often have many sad issues behind their anger.

Another version of inventing alternative behavior involves the use of books. Giving a child a book that provides fantasy material for an issue he is working on or a situation he frequently finds himself in can be a very helpful form of teaching. It may offer him socially acceptable indulgence of his situation—as when a very needy, nagging child is given a story to read about a king who has servants and slaves to...

Table of contents

• Cover Page
• Half title
• Title Page
• Copyright Page
• Contents
• Foreword
• I. Understanding the Nature of a Therapeutic Milieu
• II. Establishing Relationship Beachheads
• III. Program Activities
• IV. Managing Wake-Up Behavior
• V. Managing Mealtime Behavior
• VI. Managing Bedtime Behavior
• VII. Understanding the Stages of a Typical Temper Tantrum
• VIII. Observing and Recording Childrens Behavior
• IX. Avoiding Some of the Roadblocks to Therapeutic Management
• Index