Therapeutic Care: Policy context

Some groups – such as looked-after children, those struggling with their sexual identity, and young people with special educational needs and disabilities (SEND) – are more at risk of developing a mental health disorder than their peers (see graphics). Meanwhile, the NHS figures show that the prevalence of mental health conditions peaks in adolescence and the mid- to late-teens – this is significant for children’s services, as the largest proportion of children in care are aged 10-15 (39 per cent) and 16+ (24 per cent).

The pressure on children’s services to provide mental health support is growing as a result of a record number of children in care – 78,150 on 31 March 2019; year-on-year rises in children with a SEND education, health and care plan; and three quarters of children with a mental health condition not being referred for treatment.

Set against this backdrop, children’s services are working with health, youth justice and education services and the voluntary sector to provide therapeutic support for the most vulnerable groups of children. This stretches beyond children in care, with special needs and diagnosed mental health condition, to also include those cared for under special guardianship and adoption orders as well as young people in secure residential settings.

Many childhood mental health conditions are caused or exacerbated by experiencing trauma either as a result of neglect and abuse or due to a traumatic event in their life. Due to the wide variety of settings where vulnerable children live, there are an array of therapeutic approaches being used by service providers to support children’s wellbeing.

Therapeutic care has been shown to help children displaying violent and disruptive behaviour often caused by childhood trauma and attachment disorder. The approaches used focus on helping children to understand their experiences and find alternative ways of expressing their anger, frustration and sadness.

Therapeutic residential care

Compared to the looked-after population in general, children and young people in residential care have some of the highest levels of need, including increased emotional and behavioural difficulties. Consequently, training staff in the use of therapeutic approaches has become a key focus of children’s home providers in recent years.

The Social Care Institute for Excellence (SCIE) states that ‘therapeutic approaches’ is a term used to describe ways of working in which residential child care workers use a therapeutic perspective in their day-to-day social work with children and young people. This includes having a better understanding of how young people’s experiences affect them, considering their emotional needs and fostering resilience.

While recognising the growth of children’s homes adopting the title ‘therapeutic’, the lack of an agreed definition of what this constitutes makes it difficult for local commissioners to evaluate quality, explains Di Hart, Ivana La Valle and Lisa Holmes in their 2015 research.

“There has been a growth in ‘therapeutic’ placements, although there is no formal definition of this,” they write. “The need for treatment for troubled and traumatised children deserves more recognition.”

This lack of clarity over therapeutic placements is still an issue today, say children’s leaders (see ADCS view). This is particularly so because many local authorities look to the private care sector to provide such services, as recognised by Ofsted in its 2018 annual report. “For local authorities, it is potentially more cost-effective to buy a specialist place rather than run several homes with each specialising in a different type of care,” it states.

It was an issue also briefly highlighted in Sir Martin Narey’s review of residential child care. He recounts evidence received from one therapeutic care provider who explains that the difficulties accessing sufficient community mental health support meant that much of the therapeutic input children in residential care receives comes from children’s home workers.

“The relationship they have with the staff on a daily basis are these young people’s best chance of therapeutic experience to redress the impact of early trauma,” they told the review.

SCIE research, published in 2012, reported that 80 per cent of residential care staff said their practice had shown either some improvement or had improved significantly as a result of therapeutic training they had received. Survey responses indicated that, since the introduction of a therapeutic model, the largest improvement had been in relationships between staff and young people, followed by consistency of staff practice.

Homes with staff trained in a therapeutic approach were more disposed to manage incidents such as substance abuse within the home rather than calling on other agencies. The analysis also suggested that after staff were trained in a therapeutic approach, the likelihood of assault on staff was lower than before.

Creating a therapeutic culture

In Re-framing Children’s Services, John Whitwell, who spent 27 years working at the Cotswold Community, a therapeutic residential home and school for boys which closed in 2011, draws on the work of Donald Winnicott to describe the features that are essential for residential care to be therapeutic.

Creating a reliable and secure environment are crucial, as is the ability for staff and young people to form strong relationships.

“Practice hasn’t really changed – it’s still about relationships with children,” explains Lee Wright, director of the Mulberry Bush School.

“However, everything around that is far more complex. There is information about every aspect of children’s care and more people need access to that, so good IT is important.”

Whitwell also writes about the importance of using forms of communication and play to help children communicate how they are feeling. “It is important that these children are offered non-verbal models of communication because their ability to put feelings into words is inhibited and some of the unconscious feelings belong to a pre-verbal era in their lives,” he explains.

“At the Cotswold Community…one of the central tenets was that play is a vital ingredient in wellbeing. In the Community’s highly supportive environment, the boys were given the opportunity to discover a way of playing that was not destructive.”

Using play and other forms of non-verbal communication still play an important role in therapeutic care, however some residential care providers such as Mulberry Bush use language and verbal expression as a route into the therapeutic journey (see research evidence).

“You need to form relationships to do the therapeutic work,” says Wright. “We talk to the child all the time so that our understanding can increase and improve how we work with them.

“The whole school is the therapeutic environment. The therapist may inform that treatment, but it is the interactions that go on throughout the day that shape the therapy.

“All forms of behaviour is communication and we need to understand that. This should underpin the work of all therapeutic settings.”

Hart, La Valle and Holmes, in their 2015 review, argue that it is not just down to specialist therapeutic settings to create meaningful relationships, but all children’s homes.

“Whilst specialist and therapeutic placements are needed, all staff should be able to develop relationships with the children they care for based on an understanding of what will help them to deal with abuse, loss and trauma. Whenever children are asked, they say it is the staff who make the difference,” they write, adding that this vital role is not adequately reflected in the pay and status of staff.

Other therapeutic settings

Understanding and recognition of the therapeutic approaches used in residential child care has seen these models applied and adapted for use in other settings caring for traumatised children. For example, in 2016 the NHS funded a five-year programme to train all staff working in the youth secure estate in therapeutic approaches (see practice example). In addition to improving the skills of secure estate workers, the funding is paying for more children’s mental health clinicians to be located in secure settings to help a more therapeutic culture take root.

A significant proportion of children in secure establishments have had experience of the care system and/or been diagnosed with a SEND. Understanding the “overlapping needs” of this cohort of young people is a growing challenge for children’s services leaders.

Trauma-informed approaches are also being used to support children and young people affected by violence. For example, girls and young women who have experienced violence are using therapeutic techniques to come to address their experiences (see practice example).

There are also elements of therapeutic care in initiatives like multi-systemic therapy for teenagers who offend; the Oregon model which sees foster carers trained in therapeutic techniques that build on a child’s strengths to address difficulties; and functional family therapy for young people.

Even for children placed with adoptive families, the trauma of their previous experiences can come to the surface and in some instances threaten the viability of the adoption itself. This is why adoption support agencies like Family Futures are using the Adoption Support Fund to pay for therapeutic support for adopted children and families (see practice example).

There has been an increased focus from policymakers in recent years on addressing the mental health needs of looked-after children. Mental health assessments of children entering residential care are now routine. In 2018, the Department for Education also launched a pilot programme to identify the best assessments of children’s mental health with the aim of speeding up the identification of needs and commissioning of therapeutic support.

In addition, the 2017 children’s mental health green paper sets out plans to improve access to therapeutic care for vulnerable groups, although critics warn that more needs to be done if all those with mental health problems are to access support (see expert view).

ADCS VIEW WE NEED TO AGREE CRITERIA FOR THERAPEUTIC PROVISION

By Rachel Dickinson, ADCS President 2019/20 and executive director people at Barnsley Metropolitan Council

As we await more detail about the government’s aims for, and the remit of, the care review as well as its timetable, speculation within the sector continues unabated. It is hoped it will take a broad view while keeping a keen focus on children’s lives and outcomes. It is important that the societal challenges affecting family life as well as key policies, such as the skills and competencies of the children’s workforce, features too.

As the number of children and young people in care continues to rise, it is often the cohort of older adolescents who have complex and overlapping education, health and social care needs that dominate our thoughts. I am particularly keen to understand how the review can help us to better meet the needs of adolescents who are either in or on the edge of care, criminalisation and/or hospitalisation. With intensive, integrated help and support to stabilise behaviours and begin the healing process, we can help children and young people to achieve so much more.

A small number of secure children’s homes and secure mental health units provide the most vulnerable with highly tailored, therapeutic support. Aside from the challenges of getting a bed, it can be difficult to identify a ‘step down’ placement to support a child or young person’s re-integration into the community. This picture is much the same when a young person is released from youth custody too. Even very specialist (and costly) placements are not always equipped to care for children who have experienced abuse, neglect, trauma and personal loss.

An issue ADCS continues to raise is the absence of a common definition for specialist therapeutic provision in this context. We need to work more closely with health partners and our respective regulators to develop a clear criteria for providers to evidence the therapeutic nature of their offer.

It is also problematic that mental health services expect children and young people to be ‘stable’ before accessing services, but without support, few will find stability.

Stability should be an outcome, not an accessibility criterion and all too often a child or young person in crisis is denied access to support because they do not have a clinical diagnosis despite the clear link between trauma, emotional wellbeing and behavioural presentation. A shortage of provision and disagreements about thresholds further complicates this picture.

The needs of unaccompanied asylum-seeking children in care, who face unique social, physical and psychological challenges as a result of distressing experiences, should be given sufficient focus. The training needs of the health and care professionals working closely with this group, particularly in relation to mental health and cultivating culturally acceptable therapies and support, requires attention.

The Scottish government recently published the findings of its care review. Among the recommendations for change there was a clear commitment to ensuring that children in care, and their families, can access timely, criteria-free therapies, regardless of diagnosis. Our care review presents an opportunity to move towards a more therapeutic and strengths-based system that builds on the strong foundations of the Children Act 1989 and restates the importance of relationships.

EXPERT VIEW THE THERAPEUTIC ROLE OF MENTAL HEALTH SERVICES

By Dr Louise Theodosiou, consultant psychiatrist and author of Children and Young People’s Mental Health

Children and young people who are growing up in an ‘always on’ environment of constant information and interaction need to be supported to understand their mental health needs. Information is available about ways to stay physically healthy with signposting for people who feel physically unwell – offering the same information about mental health and resilience is essential.

Everyone in society has a role in supporting children and young people to recognise their wellbeing needs and access therapeutic care. Of equal importance is the message that mental illness must not be a source of shame and not perceived as weakness. Furthermore, the voices of children themselves is central to both addressing the needs of the individual and developing care for every future service user.

Innovations such as Improving Access to Psychological Therapies have enabled mental health practitioners to develop evidence based mental health skills. Other therapies shown to be effective for children and young people include cognitive behavioural therapy (CBT) to treat conditions such as anxiety and depression, interpersonal therapy in which young people are able to explore the patterns of difficulties they have in relationships and ways to change these, and psychoanalytic therapies which can address patterns of difficulties that stem from early life experiences.

Some mental health needs are linked to brain development before birth, for example autistic spectrum conditions and learning difficulties. The key to treating such conditions is skilled multi-agency work. Children and Young People’s Mental Health provides an insight into the way that professionals such as speech and language therapists, educational psychologists, nurses, paediatricians and psychiatrists can work together with families and schools to support children to access education and develop vital skills and peer relationships.

What must be emphasised is that each child and their family or care network, will need to be supported to navigate a different path through services. Some will need to access different parts of services throughout their childhood, for example an early recognition of an autistic spectrum condition, later support for an anxiety condition and ongoing education about their mental health needs. Other children will need to access medication for ADHD or a combined package of CBT and medication for a severe depressive episode.

Vulnerabilities such as undiagnosed ADHD or unrecognised learning difficulties can impact on social interaction, decision making and reactions to stressful situations. All of which can increase the likelihood of contact with the criminal justice system and substance use, particularly when parents also have unmet mental health needs. Therapeutic engagement with children creates a space where all needs can be explored and addressed. They need to have the opportunity for their behaviours and decisions to be understood and for conditions such as post-traumatic stress disorder to be treated alongside support with housing and unmet educational needs.

All children are enriched by a range of identities and different needs. Sometimes these needs will require specialist interventions that can be accessed in universal settings such as school nurses offering support with consultation from mental health practitioners. The children’s mental health green paper sets out the value of providing psychological interventions in school with links to child and adolescent mental health services.

Services for children and young people must be underpinned by the principle of collaborative work with children and young people themselves. Work that responds to the complexity and rapid changes of childhood and allows those children to flourish and develop the skills they need for adult life.

• Children and Young People’s Mental Health: Early Intervention, Ongoing Support and Flexible Evidence-based Care, Dr Louise Theodosiou, et al. (Eds), 2019. Pavilion
  
  
• Read more in CYP Now's Therapeutic Care Special Report

FURTHER READING

• The Long Term Impact of Therapeutic Residential Care Programmes, Probono Economics, 2019
• Social care commentary on children’s homes by Eleanor Schooling, Ofsted, January 2018
• Transforming Children and Young People’s Mental Health Green Paper, DoH, December 2017
• Residential Care in England, Sir Martin Narey, DfE, July 2016
• The Place of Residential Care in the English Child Welfare System – Research Report, Di Hart and Ivana La Valle with Lisa Holmes, June 2015
• Therapeutic Approaches to Social Work in Residential Child Care Settings, SCIE, May 2012