The experience of the child in a particular interaction is important, but positive interventions also depend on how the staff member can make use of their sense of that interaction for the benefit of therapeutic work with the child. The staff member then has greater ability to become attuned to the child’s subjective experience, and can make sense of those experiences. In this way, staff develop an improved ability to communicate them back to the child through the subtle nuances of behaviour (e.g. eye contact, tone of voice, responses to behaviour) which arise throughout the day to help reframe the child’s expectations and beliefs.

The skillful work based on the here and now. undertaken by the therapeutic residential care staff can help the child to cope with the internalised narrative of the past. The child views themselves as good or bad, smart or stupid, depending on what messages they have gained from their experiences. These are often heard in the child’s dialogue; for example they may say "I am bad" or "It’s all my fault". The messages that the child gains from the experience of therapeutic residential child care can slowly challenge and change the internalised messages received in the past. Staff should aim to help change the child’s beliefs relating to self through natural positive reinforcement of the child’s strengths and abilities.

The Five Rivers Approach To Assessment

As can be seen a crucial part of the therapeutic residential care approach is the ability to understand and make sense of each young person’s needs and behaviours. This is done by undertaking an assessment process which aims to construct knowledge of the young person’s developmental history and current functioning.

This process is dynamic and ongoing throughout the young person’s placement. This information is then used to make sense of and understand their current behaviour and how this relates to their overall emotional and social functioning. This process takes place for all young people and within a culture of openness and informed consent from the outset. The process openly acknowledges the experiences of many of the young people who may come to stay within residential child care and utilises appropriate assessments (Trauma Symptom Child Checklist, Adolescent Dissociation Scale, Adolescent Multidimensional Inventory of Dissociation and Child Dissociation Checklist).

Outcomes are also based on maintaining realistic expectations of children and understanding that children and young people within our care can regress to a younger age and will think and behave as a child much younger than their chronological age. As such, staff need to respond to the child at that level, and tailor the assessment process to account for this.

How Does All This Fit Together (The C.A.R.E. Model)

The aim of the C.A.R.E. model is to provide a Consistent, Attuned, Reframing intervention which creates new Experiences. Consistency comes from the provision of clear boundaries and consistent responses from staff. Being attuned means that staff are child centered, truly responding to the child in a individualised attuned way and understanding about the basis of the child’s behaviour. Reframing means that every opportunity is harnessed to help reframe the child’s past experiences in a natural nurturing way. This in turn helps the child to understand and to benefit from new experiences. This approach not only forms the foundation for the therapeutic work but also helps the development of the child’s integrated sense of self. A simple pictorial diagram of the approach is given below:

It provides a potential space where it is safe to think about the trauma, experience feelings about it and create the correct holding environment where healing can take place (Miller, 1993; Ward, 1998). This means that the adults responsible for the child’s care have a huge responsibility to be there to care for them, not just some of the time but all of time. In effect, the staff become part of the therapeutic parenting team.

In this way the milieu or life space in a group living environment becomes a focus for the staff to use daily events and processes as part of therapeutic work. The care staff can provide a responsive environment which manages the boundaries within which the child behaves. This will ultimately assist the child to manage and regulate their internal affect. As we have seen, dissociation is utilised to protect the individual from overwhelming anxiety. Without realizing it, I fought to keep my two worlds separate. Without ever knowing why, I made sure, whenever possible, that nothing passed between the compartmentalization I had created between the day child and the night child (Marlyn Van Derbur (2004, p26)

An alternative reframing environment should be created by staff to help the child to alter their perception of the world and of self. In this way trust in the outside world becomes the foundation for self-trust and self-care as the child or young person grows and develops.

It is essential that staff strive to create a safe place in the real world so the child doesn’t need to retreat to their inner world. The C.A.R.E. approach embodies the notion proposed by Heard and Lake (1997) about supportive companionable. relating within a safe environment.

The importance of understanding the child’s behaviour a child who has been abused carries around a set of habitual expectations and responses

specifically designed for survival. The child has developed mechanisms and behaviours to provide themselves with a sense of safety and control in situations where they had none. Staff continually strive to make sense of the child’s behaviour. This pattern is called a trauma bond (Herman, 1992; James, 1994).

Staff need to be supported do not take any of the behaviour personally (e.g. angry acting out). This can be particularly difficult when the child is violent, damages the carer’s property and attempts to test the messages provided by the adult. By reframing the child’s behaviours, one can see these as opportunities to undertake meaningful work and to question where the behaviour fits into an old pattern. In this way, staff arrive at a betterunderstanding of why the child copes in a certain way.

By reframing, staff learn to view the behaviour as the child’s way of communicating, and are then able to use this understanding to help inform formal therapeutic interventions. If behaviour is seen as a type of communication, it may be asserted that some behaviours only occur if formal communication breaks down. This can be a challenging concept, but by looking at violence as communication, for instance, it provides an opportunity for reflective practice that staff can harness to improve inter-relational understanding and outcomes for the child.

For staff to be able to make sense of the extreme transference and chaos within the child’s inner world, they must remain grounded and self-aware. In doing so they are able to react calmly and non-punitively in the face of a child’s anger and anxiety. Support structures are utilised by all staff (e.g. supervision and team meetings) where the focus is on processing, and ensuring understanding of, dynamics, feelings, and how best to meet the child’s needs (Tomlinson, 2004).

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