Psychodynamic thinking in social work practice, in P Stepney and D Ford (eds) Social Work Models, Methods and Theories.

2nd edn. Lyme Regis: Russell House (publication date: May 2012)
July 2011

Child Protection Case Conference The case conference was well attended, with nine professionals and both parents who had recently separated. The atmosphere was uneasy. The concerns about the children were border line child protection, and de-listing was certainly an option. However, the mother presented as scatty and confused. This seemed to have the effect of galvanising various professionals to step in with robust advice. At one point the chairperson homed in on the mother and challenged her vigorously about her approach to running the family home. The mother had been saying that she muddles along and most things get done one way or another. The mother was both intelligent and articulate and there was a sense that this just wasnt good enough. The challenge continued, without leaving a stone unturned and eventually the mother was in tears. I was aware of feeling uncomfortable throughout this process, as it seemed so unnecessary, and I was also aware that this was an uncharacteristic intervention by the chairperson, who is usually very supportive of family members at child protection conferences which can be so daunting. I found myself mulling over the conference for the next few days, and feeling agitated about the mothers vulnerability. What came to mind was my knowledge of the family history. This mother had a poor relationship with her father, who she felt was emotionally cold and critical, constantly disapproving of her. It seemed possible that the conference had been an enactment of that relationship, with the mother falling into the role of vulnerable child victim persecuted by a harsh parental figure, whilst perhaps also wanting to distance herself from an overly critical part of her own personality, which was split off and projected into any authority figure. I kept this in mind during subsequent work with the mother, and talked to her about her tendency to present herself as less competent than she really is. I also endeavoured to avoid being provoked by the mothers somewhat contrived ineffectualness, which could be exasperating and leave me feeling inappropriately punitive towards her. As the work progressed we linked these moments, where she seemed to be setting me up to criticise her, to her experience of her father. Over the next few months the mothers presentation at multi-agency meetings became more confident, as she started to own her own critical voice and make it work positively for her, and the professionals concern for the children diminished. Discussion points: Splitting and projection, enactment, power, reflective practice, unconscious process

The Family Court A grandmother seeking special guardianship of her three grandsons was required by the Court to undergo extensive psychological assessments. The assessments were thoughtful and clear-sighted, identifying areas of vulnerability as well as strengths, ultimately recommending that the boys remain

with their grandmother. However, during these assessments it had emerged that the grandmother had been seriously sexually abused as a child. Although the recommendation of all parties was in the grandmothers favour, she started to become very agitated about her own adult children finding out about the abuse, and gave her solicitor such stringent instructions about restricting their access to the information that I started to worry that the positive outcome would be jeopardised. It also seemed to me that her fears were irrational as her sons and daughters would surely be sympathetic . I felt it was important to try to contain the grandmothers anxiety and made a point of responding to all her calls and visiting frequently to talk it through. My hypothesis was that the grandmothers childhood trauma had been re-awakened at an experiential level by the deeply personal exposure and unwelcome intrusion of the Court proceedings. She was struggling with feelings of shame and guilt derived from the abuse and these painful feelings were now being expressed through her relationship with one of her daughters in particular who she also felt she had let down. I knew that when she was ready the grandmother would seek specialist counselling but my immediate task was to support her through the Court proceedings so that her understandable and very human response to the rather de-humanising legal process could be acknowledged and held, and not pathologised as a symptom of emotional instability. I was also very conscious that it would be devastating for the boys to be removed from her care, so this was a crucial moment in the care proceedings, which meant everything to the grandmother, even though the other parties were oblivious to her distress, as they believed that the key decisions had already been resolved. Discussion points: Containment, trauma, child focus, hypothesis, regression, repression

Processing feelings in supervision Working with a difficult and abusive father my student found herself full of feelings of anger and condemnation. We talked about the family history and used a genogram to wonder about various possibilities in the family dynamics. Using her experience of meeting with family members my student was able to consider how this father had himself been abused, his needs overlooked and his siblings preferred. Various patterns emerged, including abandonment, the desire to control the uncontrollable and inconsistent parenting leading to profound distrust of all relationships. This process helped my student to moderate her feelings and allowed her to also have other emotional responses towards the father, such as empathy and respect. This enabled her to feel more confident of her risk assessments in relation to the children as she was freed from the burden of feeling punitive and reactive. The relationship with the father remained difficult but my students stress levels reduced as she felt more competent and fully engaged with the work, no longer restricted by a too rigid and limited perspective. Discussion points: adult attachment, loss, personality disorder, reflective practice, use of self, systems theory, hypothesising, non-judgemental stance.

Case discussion A social worker presented a case to a small group of peers that was troubling her as she feared that she was under-estimating the risk to a young baby whose mother had mental health difficulties. The

mothers home was a mess and seemed to be deteriorating and the police had been called by neighbours following a row with her boyfriend. The social worker had visited on a Friday evening and had spent a long time talking to this young mother and helping to soothe the baby. She allowed the mother to send her texts and visited again on Monday morning. After a few days of visits and other contact the social worker started to feel anxious that she was getting drawn in to a dependency relationship with the mother and worried that matters would deteriorate again if she reduced the level of involvement. The group established that the babys needs were being met and that the mother seemed to be bonding well. The discussion moved to a consideration of the mothers attachment needs. She had had a chaotic childhood, living with various family members and as a teenager moving to live with a friend. As an adolescent this mother had engaged in risky and challenging behaviour, which led eventually to her being placed in a foster family, who had cared for her well. The group considered how this behaviour had led to good outcomes for the mother and that it seemed that she was reverting to similar tactics now. The group felt that the mothers behaviour had been an activation of care rather than a symptom of dysfunction. The relationship she was seeking with the social worker was an anxious attachment, but it was also an indication that the mother did expect to get her needs met, even if she was regressing to adolescent tactics. This seemed to be an effective internal model and by extension indicated that she expected her baby to expect to have his needs met. The effect of the case discussion was to reassure the social worker that she was not under-estimating the risk to the baby and this enabled her to continue to support the mother by helping her to develop insight into the way she elicits care for herself and to start to think about alternative ways of doing this that might save her from risky behaviour and understand her babys needs for a healthy secure attachment based on her anticipation of the babys needs and meeting them with consistency and predictability. Discussion points: attachment, containment, group supervision, risk, using behaviour as a form of communication.

Home visit I worked with a mother with a history of mental health difficulties and self-harming. Her relationship with her five children was very warm and attuned and she was able to see each child as an individual, encouraging them and setting appropriate boundaries with energy and humour. However, she could not keep her house tidy and it was in a very poor state, with a dirty kitchen and heaps of clothes and papers on every floor and surface. On a number of occasions I got stuck in, and tidied the house with her. Each time I noticed that as the house got tidier her mood sank. When the house was a mess she was cheerful. I struggled with this phenomenon for months during which time we talked about her childhood and what the mess might mean to her. The key issue for this woman was that she had not been removed from her abusive parents until she was six. In her mind this was an injustice that could not be forgiven as she felt she should have been removed much earlier. She said things were terrible for her and no one did anything. She had a sense of being invisible and something being terribly wrong. After a while it emerged that she felt the mess represented a visible wrongness, and that if it was tidied up then the wrongness would also disappear, or become invisible again. She managed to calibrate the mess so that it hovered just under the threshold for a referral to child protection. Eventually, the case was closed, as the

children were thriving, and there was a better understanding of why she just was not ready to lose this tangible symbol of the fact that she had suffered harm as a child. Discussion points: relationship-based social work, observation skills, risk assessment, child focus, power, interpretation. Talking to a child I had a bag of duplo figures and I let Sophie, age 7, play with them. After a while I prompted her to show me something about the people in her family. She immediately assigned identities to the figures and created different spaces for the kitchen, the front room and outside the house. She enacted an interaction with herself and her mother which was an argument in which she was told off by her mother, but then her mother asked her to get her a drink. Sophie made the Sophie doll go to and fro between the front room and the kitchen getting her mother drinks. The tone of this was aggressive and angry and there was one drink after another until the mother doll collapsed and fell over. I asked about some of the other characters in the family and she immediately identified a figure as her step-father. She made the step-father take each of the other children into the kitchen. Then she created a bad man, who she placed outside the house. The step-father came out and had a fight with the bad man chasing him away. Then Sophie let some of the children out of the house and the bad man started to attack them. The step-father intervened, again herding the children into the kitchen. She then made a strong front door which the step-father guarded. The play then involved the bad man making attempts to get into the house, and each time the step-father fought him off. I asked if Sophies step-father made her feel safe and she said yes, very emphatically. I asked how she felt about her mother and she flicked the mother doll out of the house, but Sophie made no attempt to make the step-father rescue her from the bad man. This was a family where there was considerable concern from the police about the step-father, who wanted the mother to have sole care of the children following an incident of domestic violence. This play session provided an insight into how Sophie felt about her carers and persuaded me to re-assess the role of the stepfather, and indeed the mothers abuse of alcohol. It was not clear if the bad man represented an individual or just a general sense of threat, but it was clear that Sophie felt that the step-father would protect her. Discussion points: Play, the childs view, risk assessment, gender and violence

Managing anxiety A mother asked to speak to me about her childs refusal to eat. She was in a very anxious state, feeling that she must be doing something wrong and that her daughter would come to harm. I pointed out that she was a robust child with a strong personality and maybe she was experimenting with what effect her actions could have. The mother then rewarded the child by reacting with excessive attention. I advised her to stay calm and if the child refused to eat simply take her food away and start another activity, then not offer her food again until the next meal was due. I suggested that it was the intense emotions she was interested in and if the mother became less emotional she would regain control. The mother agreed to try this as she could see it made sense but she said it made her feel very upset to think that her daughter might be hungry or under-

nourished. Knowing that her own mother had been neglectful and that she had not had her needs met as a child I suggested that this scenario, related to feeding and nurturing, was putting her in touch with her own little girl nearly thirty years ago, who had had a really bad time and who had not been properly looked after. I suggested that she needed to take care of herself, and allow herself to feel sad about herself as a vulnerable child, and not to worry so much about her daughter as she was clearly thriving. The mother recognised this distinction and stated that she could see that she should not impose her own experiences on her daughter, as her life is very different and she is loved and cared for. A week or so later the mother reported that the refusal to eat had disappeared completely. Discussion points: acknowledgement, displacement, inner child, re-framing.

Drug abuse A young mother with three sons had been a crack user and relapsed whilst waiting for a rehab programme to start. The experience practitioners have of working with this mother was that she was exasperating, constantly missing and cancelling appointments, providing spurious excuses and flouncing off when challenged. The child protection plan had focussed on compliance with drugs tests and other behavioural matters such as keeping her home tidy. She would complete a task halfheartedly and have a more or less plausible reason for not doing the rest, making it difficult to decide whether she was making progress or slipping back. I held a meeting with the other professionals where we decided to change tack, and drop the idea of behavioural compliance. Instead we all agreed to focus on the mother as a person, her thoughts and feelings, her life story and her hopes for the future. We decided that there would be no repercussions if she didnt turn up to appointments, and that we would just calmly re-make an appointment. This led to an improvement in the mothers engagement, and a change in her demeanour, from lots of bravado and provocation to her becoming more tearful and sad. This work is not complete but the consensus is that this mother is more likely to sustain abstinence in her current state of mind as she is allowing herself to be supported. There is a sense that this unwavering support is addressing some of the deficits experienced by this mother in her own childhood, where she was constantly abandoned and let down.

Discussion points: adult attachment, containment, positive regard.