The Therapeutic Milieu Approach
This model is based on a therapeutic milieu approach in which the relationships the child has within small therapeutic group residential homes are harnessed to improve outcomes for young people.
The model emphasises the importance not only of a quality of the relationships but also the quality of the environment. A positive experience of both can improve the therapeutic outcomes for the child. In this way the Consistent, Attuned, Reframing new Experiences (C.A.R.E.) approach becomes the therapeutic footbridge which the child or young person can use to step onto a path of feeling, knowing and finding oneself.
The Basic Foundations Of C.A.R.E.
Many of the children with whom the author has worked in residential care have experienced severe disruption in their early years of development, as well as high levels of neglect and abuse. The child’s world has often been characterised by chaos and staff need to work hard to establish a basic foundation as a platform for work. The creation of this basic foundation is about providing the very fabric of structure of experience and containment that the traumatised child needs to recover and develop.
This structure is provided through basic care. Hence, one of the key messages about any therapeutic approach is not to forget basic needs. What may seem small and insignificant to staff when they are used to it can be crucial in sending a message to a child that they are safe (for example eating well, staying warm and clean, and attending to health).
No child who has experienced trauma and who may use dissociation to cope with the effects of trauma is going to heal and learn to use different ways of coping without first feeling secure. Donavan and McIntyre (1990) point out that verbal reassurance is rarely enough for a child and that they first need to experience safety and environmental protection in order to feel safe.
For children who have experienced chronic trauma, the importance of environmental interventions can be overemphasised and is viewed as essential (Shirar, 1996, p 146), in terms of providing the stable and safe place from which therapeutic work can be undertaken.
Traumatised and dissociative children can be hypersensitive to change due to their past experiences of unstable, disorganised and chaotic environments. Sadly, this can be replicated when they become looked after. For example, many children experience a repeated pattern of placement breakdown prior to coming into a residential unit. In order to help them cope with change, they therefore need a stable physical environment and clear cut daily routines and expectations (Putman, 1993). The stable environment is transmitted to the child through the consistent approach of staff to their care. Stability is also represented by the internal fabric of the unit.
In psychotherapy, for example, it has been acknowledged that even the slightest changes in the therapy room can increase anxiety for the chronically traumatised client. Therefore, if the internal fabric of the house is being changed, this should fully involve the child, so that they understand fully what is happening, why it is happening and also be part of the process. To provide a sense of safety, another crucial aim is to provide a culture of unconditional care and be there for the child for the long term. This means putting boundaries in place and communicating about unacceptable behaviour in a way that helps the child’s understanding. Unconditional care not only provides safety but also an environment that is nurturing and able to provide comfort.