Rehabilitation and the Family -  "What do we hope to achieve?"

This year has seen me reeling from one intense court case to another - Should this mother be allowed a chance to have her child back? - Should a child be brought up by her natural parent? Can you achieve good bonding after prolonged separation? Is a child more harmed by failed rehabilitation than no rehabilitation? Should a teenage mother be encouraged to bond with her child? What is the aftermath of parental loss? Clichéd questions coming up time after time. Nevertheless hard to answer in the harsh glare of the court scenario when respected colleagues argue against each other - quoting contrasting literature and research findings with equal zeal. 'Zeal' is I feel, the right word for it - there are few areas where passion, and subjective fervour are more apt to cloud objective judgement than in that of child protection and separation of parent and child.

Certainly there is a difference in perspective - social workers do not want a dead baby on their case load and know the media will point the finger of blame in their direction; paediatricians may see neglected children gaining weight in hospital away from their families; child psychiatrists look at the disorganised family structure and find it hard to see a child being able to overcome parental patterns.

I wonder sometimes quite what we are hoping to achieve when we take the other view? What are we doing in our rehabilitation programme? With success rates running at perhaps 50% - if you're lucky and how do you measure success anyway? Varying criteria for selection for rehabilitation and no consensus on long term goals. Helping disturbed mothers parent disturbed children can seem a thankless task.

Unless you work with adolescents. That is when you begin to see the point. What do we see as the child reaches adolescence? And what happens when that child becomes a parent? Removal from the family is sadly not a panacea - we see young people whose self esteem is in their boots - crying out to know why their families did not want them, why they failed their parents so badly - and often recreating their own family disturbance and imagined parental traumas in an attempt to understand and identify with their absent parents.

Mark was placed in care at the age of four, lived in children's homes and then a 'good' foster family. He did well at school and college, gained professional qualifications and then 'blew it all', lost his job, on the verge of divorce and with seething rage directed at his four year old daughter. He remembers nothing of his early life but his fantasy is that his behaviour was so bad that his parents had to send him away. He needs to somehow prove that his parents were good and he was bad by recreating the scene in this generation.

A teenage mother may well prove, with help, to be an excellent parent, able to meet her child's needs in a way that cannot be faulted. On the other hand she may be too much a child herself, needing love, care and attention which her child cannot supply. The same situation could apply to a mother who is for other reasons unable to meet her child's needs - by virtue of mental or physical illness or deprived circumstances. It is important that such mothers (and fathers) be given the chance to explore their own potential - to be supported and encouraged and to be allowed to share in the decision whether to parent their own children or give them over to the care of another.

I know how grateful fourteen year old Kim was when I asked her if she would like me to find a foster mother for her child.  She had wanted so much to please us all by being a good mother - but the depression and loss of herself showed through. At the court hearing they called her an unfit parent and brought up all her past delinquency - several months work on self worth destroyed in a day. But her little son will know, when he reaches his adolescence that he was a valued child, that his mother tried her best, and then gave him up in love.

I am constantly being told by my paediatric colleagues that good bonding between parent and child is essential for future mental health and that this can only occur in the first year of life - many authors have disputed this time limitation and even Bowlby has revised his views. However - even if this were so - surely the chance of establishing a rapport with your own mother - at whatever age is preferable to whatever bond may be established with a stranger?

Winnicott  once wrote a paper titled "Delinquency as a sign of hope". Rebelling, pushing out against the injustices that you have suffered in childhood - that is indeed a sign of hope - a sign that the spirit is not broken, that there is an individual in there shouting out "Hey! What about ME!" The beginnings of change, of a sense of one's own needs, of self worth.

Adolescence is regarded traditionally as a time of 'delinquency' and rebellion, a time of  change and energy - both can be channelled in the healing process and that is often what makes working with young people so exciting.  However the 'adolescent process' can be seen in many phases of change. An abused 'victim' who begins to assert himself, a 'battered wife' who gains the courage to leave her husband, a drug addict or alcoholic who decides to opt for a different lifestyle - all enter a new way of being - all experience the honeymoon elation of starting on a fresh beginning - they all in their own ways feel the exhilarating freedom of an 'Adolescence'.

Thus , just as for the adolescent, we can make use of this energy for change in the rehabilitation process for our damaged families.  And , just as in adolescence, we must appreciate the stages of this process and work through them with our patients - understanding and support is the cornerstone - coercion and ultimata have no place in rehabilitation.

The damaged parent of whatever age, needs to go through a stage of being allowed to be the 'needy child'  - for that indeed is what he or she is.  Years of deprivation and abuse have usually taken their toll in terms of the individual's needs never having been met. A young parent generally becomes a young parent partially to find a way to fill this unmet need. A common mistake is to either disregard this need entirely, or to somehow expect it to be dismissed at will. How often have we heard the expression that a parent is "Unable to place the child's needs above her (his) own".  As if this were a conscious decision.  OF COURSE they can't!.

The answer lies not in condemning this need, or pushing it to one side - but in fulfilling it. A needy parent is like an empty vessel , without caring or 'mothering' to fill the void - they have no resources - nothing to give their children. So our first task is to accept the needs of the patient's inner child, to allow them to be child like and to parent them - often for the first time in their lives. Here 'dependence' is healthy and a required stage in the treatment process - however, like all good parents, we need to set boundaries and be consistent in our caring during this childlike dependency stage.

As the patient grows in trust and confidence, we also, as good parents, relinquish some control and responsibility so that our 'children' can grow up. Having had some of their own needs met, they can now look to their own children's needs - but gradually at first. We take them through Bowlby's 'exploring from a safe base' , we ARE that safe base. They go through an adolescence with us 'holding' and 'containing' their anxieties and gradually emerge as competent adults.

Let us not forget that all parents need a measure of 'parenting' themselves. Not just as a model, a way of building up the 'inner parent' by example as described above. But also when giving birth, at the time of becoming a parent, we also need to be cared for - to be 'mothered' or cared for by a loving partner. Those who often need this most - our deprived or damaged patients, are those least likely to get it. And to make matters worse, they have far greater traumas to bear during the early months of parenthood - single parenthood, domestic violence, poverty, poor housing, inexperience etc. etc. In addition they will suffer greater stresses and assaults to their self worth and their parenting - criticism, children failing to thrive, childhood illness, professional intervention (usually perceived as unhelpful and critical), case conferences, child protection procedure and possibly court action or assessment.

It is too easy for assessment and observation to become negative, destructive and almost a sneer from the sidelines rather than a productive process. There is no value in watching a sinking man drown - if you see he can't swim, you throw him a life raft. So there is no value in purely observational assessment - seeing a faltering parent damage herself and her child holds no joy for observer or observed.  Such an observer deserves to bear the shame of such failure and is a perpetrator of abuse to child and parent alike.

Assessment means 'working together ' to see what can be achieved and what can not. It is only in this way that a fair evaluation can be made of the situation and one that has a chance of being accepted by the family. So I suppose that I have answered my initial question "What do we hope to achieve?"  - We hope to achieve a realistic appraisal of a families strengths and weaknesses;  a forward plan which will best serve the needs of each individual within that family as well as the needs of the whole ; and an appreciation of the dynamics of the situation which is not based on blame, fault or failure, but rather on understanding, empathy and regard.