Kees Maas and David Ney

Youth care in residential treatment settings is a highly complex, well-timed series of interventions incorporating a multitude of practical and theoretical knowledge and skills, and a healthy measure of intuition. This paper focusses on the complementarity of clinical supervision and consultation as a support to the youth care worker. Through the use of a case study, the authors — a clinical psychologist and a program manager — describe their experience.

Youth care involves the overseeing of, and the participation in, almost every conceivable daily activity. The setting in which the authors work together provides service at the most structured level to adolescents under criminal and/or protective court orders. In this setting the youth care worker is more often witness to the residents’ impromptu emotions and impulsive behaviours than are intervenors who schedule time with them (e.g., social workers, doctors, program managers, psychologists, etc.).

The mufti-disciplinary team approach is accepted as the only practical means of providing adequate care. The authors contend that within this team each member requires specific clinical supervision and supports commensurate with her tasks.¹ This paper is devoted to the specific needs of the youth care worker.

Emotional supports can be manifold. First, all youth care workers, like other professionals working with youth and families, need to be aware of and understand their own emotional reactions to particular youth and families, as well as their reactions to certain problematic themes (e.g., abuse, sexuality, depression, and psychiatric illness). In order to explore these emotional reactions, one needs to feel that it’s all right to react emotionally as a professional and that these reactions can even shed light on certain issues of the youth and/or her family.

Working together as a team is not always easy and can trigger both positive and negative emotions. Furthermore, work with youth and families triggers many emotions that need to be vented regularly individually with a colleague or supervisor and collectively as a team. Disagreement is a necessary and useful means of clarifying and understanding cases. The problem arises when disagreements are personalized and thus linger on beyond the discussion at hand. The role of colleagues and supervisors is to point out and help work through relationship difficulties between members of a team.

Instrumental support refers to the flexibility of the work schedule, the sharing of tasks within the multi-disciplinary team, the availability of supervision or consultation, assistance on the floor and/or during an intervention, and internal or agency-supported external staff development.

Conceptual support links theoretical knowledge with personal conceptions of, for instance, family, parenting, youth, adolescence, normalcy, and so on. One must be aware of how much one’s practice is influenced by one’s personal ideas about normal family functioning and activities that are ageappropriate. One needs to distinguish between one’s own issues and the issues of our clients.

Youth care requires knowledge about a host of subjects including:

• intrapsychic dynamics

• family dynamics

• small social systems’ functioning (e.g., gangs, cultural value bases)

• dynamics of therapy/intervention: transference and counter

• transference, process of intervention, planning

• awareness of alliances, identifications, and triangulations

• normal psychosexual development

• emotional deprivation and neglect

• psychopathology and personality disorders

• violence and self-destructive behaviours (suicide, self-mutilation, substance abuse, prostitution)
  

One also needs to reflect on how one works, how one conceptualizes the practice of youth care, and how well theory and practice fit.

Institutional supports refer to the need for clear institutional guidelines, concerning, for instance:

• job description and job expectations

• philosophy and model of intervention

• vision of interdisciplinary collaboration

• ethics of practice

• supervision and on-the-job training

• general mandate of the institution

• complaint procedures

• investigation procedures

• other policies concerning aspects of the practice
  

Ideally these policies should be well integrated into the practice and not just remain a nice collection of binders that sit in the workers’ offices. This integration into practice shows up in the clinical procedures and customs of a unit or a service. Supervision will also play a key role in this integration between institutional policies and clinical practice.

As well, the organizational aspect has become negatively associated with job evaluation and risk of disapproval. It is both the supervisor’s and the youth care worker’s role to help create a balance between both aspects so that the supervision becomes less reactive and more proactive and supportive on a regular basis.

Clinical consultation can be delivered by professionals from within or outside the organization. In our case, consultation is provided free of charge through a service contract with another public service agency. The service contract stipulates objectives for the consultation with each individual unit of the agency as well as time frames in terms of availability and frequency of meetings. The contract also specifies the different modes of consultation made available to the agency.

The purpose of consultation can be provide an opportunity for both the team members and the unit coordinator to join in the reflective and problem-solving process with an exterior person, thereby taking the discussion out of the realm of daily decisions and issues of authority.

The objectives of our clinical consultation are to:

• provide support to the child care practitioners

• provide distance with the practice in individual cases and globally with the unit programs

• provide a specific professional perspective, complementary to the youth care team’s expertise (e.g., the psychologist brings developmental, maturational, and intrapsychic perspectives; the social worker focusses on the family system, interpersonal relations, relationship with the community, and so forth)

• assist child care practitioners in understanding cases and in formulating treatment strategies

• discuss themes relevant to child care practice

• acknowledge the affectional/irrational component of child care

• practice (transference/counter-transference)

• qualify the practice of child care workers
  

Consultation can be delivered in several formats and in different settings. It can be built in as a permanent component of the clinical process, in which the consultant meets regularly with the youth care team or sub-groupings of it to discuss clients and/or program issues. The regular presence of the consultant allows the building of mutual trust and respect. At times, the consultant can be helpful in crisis-provoked meetings in order to provide support, perspective, and distance as a person not involved in the crisis, thus enhancing the debriefing process.

Occasionally, consultation can focus on thematic discussions in order to broaden the understanding of individual cases and to refresh the theoretical knowledge on certain youth care related themes. Furthermore, in the case of a clinical psychologist consulting with the team, the consultation can be in the form of meetings with individual clients, families, or subsystems of the family, in order to get a better understanding of individual and/or interpersonal dynamics. This understanding will help the team in the treatment of the youth and her family.

Pauline is a sixteen-year-old female adolescent who has been living with her mother since the separation of her parents not too long ago. She has one younger sister who is still at home.

The parents’ initial contract seemed to be one of simply having a good time together and taking care of each other on an “on demand” basis. While this is a stage that most adolescents go though in their beginning explorations of relationships, it is a very egocentric start to the sort of relationship that needs to develop quickly as the individuals and couple mature. This couple remained very needy and immature; this was further exacerbated by the birth of their two daughters and the change in their responsibilities and lifestyles.

Mother had been struggling with a drinking problem for most of her life. She was the product of an abusive father and an absent mother. Her struggle for adequacy and success was evident in all interactions and interventions with her children and husband.

Father came from an intact family; however, he had clearly not separated, physically or emotionally, from his parents despite his marriage. Father did manage to maintain a professional career throughout his marriage and the couple’s separation. Of note was the particularly close relationship that Father had developed with Pauline — one which was highly sexualized without having been physically incestuous.

The issue of boundaries for this couple as husband and wife and as parents was of primary concern as their level of immaturity allowed for an equalizing, if not a reversal, in the family hierarchy. This led to competition between the daughters as to who would have control; at the same time, the parents were involved in their own confrontation as to who was taking care of whom.

The enmeshment of all family members and Pauline’s and her sister’s resultant acting out led to their placement. Pauline had been placed for six months as the following problem was unfolding.

Problem in Residence
Pauline did not follow the basic expectations of the program and found ways to disrupt the normal functioning of the unit, the workers, and the other youth in care.

In placement Pauline struggled for control as she had done in her family; this took the form of nonsensical behaviours such as staring into space, use of non sequiturs in conversation, extreme and unprovoked use of profanity, and seeming disorientation to time and space. Pauline used an enormous amount of the staff’s energy in the unit, and they quickly found it impossible to make use of the basic formulas that worked for most youth in care at a strictly behavioural level. Their interventions were limited to continual responses to Pauline’s behavioural cues; any process more evolved than one of control seemed to be beyond their reach.

Supervisory Process
Supervision of all workers, including that of the primary worker, initially took the usual routes, for example, discussing the reasons for placement, the basic family dynamics, intervention plan orientation, and so on. This quickly shifted to problem-solving as Pauline’s behaviour became more and more

all-invasive. Within this, the supervisor and the team became embroiled in the same process that had been going on at home and that was being duplicated on the floor, and they were becoming unproductive and very frustrated. This led to feelings of professional inadequacy and a dynamic of mutual blame — again, a carbon copy of the family dynamics.

The process in supervision included the following:

1. Individual supervision with each team member and most relief workers and conversations with most covering supervisors indicated that there was absolutely no appropriate focus in this case — everyone was singling out this youth as more and more “psychiatric,” which (within this centre) meant questioning whether she was in the appropriate unit. Attitudes overall were helplessness, frustration, and anger. Dozens of examples were given, essentially giving credence to the perception that Pauline did not fit in, and that she was possibly “at risk” in the group.

2. Supervision of the primary worker found her feeling overwhelmed, guilty, and responsible for Pauline’s behaviour in the eyes of her fellow workers. This youth care worker had a great deal of experience with very difficult youths, and yet felt that she was now without direction or support. The worker tried a number of different methods with Pauline, including the development of a “shadow” program which necessitated the cooperation of the rest of the team. In this type of program, the youth and the staff must remain together through the events of the day. Inherent in such a program is the staff’s clear understanding of the youth’s dynamics and their commitment to the treatment path and the dynamics that the intervention plan has put forth. Included is a clear set of techniques and predictable staff responses to behavioural cues from the youth. The program failed. Program evaluation led to the unavoidable conclusion that it had been unwittingly sabotaged by the staff team. The primary worker was coping with the same types of ‘resistance’ that the team attributed to Pauline and her family — the team’s insistence that this was her (the primary worker’s) problem isolated her from her colleagues and actually became the greatest concrete example of the team’s concern for the youth being at risk. The primary worker was a part of an enmeshed system including the youth and the rest of the team; as this was an unconscious process, she was unaware of these dynamics. It was clear to her, as it is clear to many families whose children we treat, that something was not right, and that she was becoming less and less able to effect change.

3. The next part of the supervisory process was to look for entry points so as to begin to effect change in the team dynamics. In order to do so, the supervisor had to gain some distance from both the team and Pauline’s case. She was in danger of becoming just as much a part of the system as was her team.

4. In effect, the supervisor levelled the playing field by challenging the team to be able to give appropriate treatment to any youth despite their assessment of where she might better be placed. The supervisor’s commitment was to concurrently explore alternatives on their behalf if they could assure the youth’s safety in the unit.

5. The next step was to take advantage of the availability of a consultant in order to help shift the unit dynamics. The situation had developed to the point where the primary worker and the supervisor were being blamed for the difficulties that everyone was having with this youth. As soon as blame existed, the hierarchy became part and parcel of the problem. Therefore it was impossible for the supervisor to lead or to even take part in an objective clinical discussion. Her team needed the opportunity to discuss the issues without the pressures inherent in the above relationships. Introducing the consultant in the reflection around this case allowed her and her team to all take a step back, regain their objectivity, and look at everyone’s role in the midst of the confusion that Pauline was provoking.
   

Two problems were described to the consultant:

Problem 1: The workers found themselves focussing on Pauline’s behaviour, getting irritated, protecting other youth from Pauline’s silliness, and in the process, losing sight of the underlying dynamics leading to this behaviour — in other words, the workers found themselves treating the symptom rather than the problem.

Problem 2: The primary worker for Pauline, although stuck in the same process as all the other workers in the case, was also under an enormous pressure from her frustrated peers to do something about/to/for her client. The team had gone an extra step beyond what is usually the case by identifying the specific players within the family dynamics — e.g., the primary worker became Pauline’s incompetent mother, while the remainder of the team represented the helpless father.

1. The usual consultative process was agreed upon: meetings in two stages: (a) among the primary worker, the supervisor, and the consultant, and (b) between these “players” and the rest of the team. In this case it was a particularly helpful process because it confirmed for the primary worker that she had a “real” problem, and that the problem wasn’t her. She was able to air her frustrations with respect to both the youth and her co-workers. Linking the emotions (frustration, helplessness, and anger) of the worker to the mechanism of projective identification allowed her to gain some distance from the case. Projective identification is a process in which a person who is the recipient of another person’s projections of negative feelings (particularly anger and sadness) identifies with these feelings and thus experiences them as her own (Ogden, 1979). This process entails initial splitting or separating out of the good and the bad feelings. It serves the purpose of eliminating ambivalent feelings toward significant others. This process occurs in the infant stage of child development as a means of maintaining the illusion of fusion with the primary caregiver. This serves particularly to encourage mastery of the hostile feelings triggered by the unavoidable frustration of needs that occurs because the caregiver cannot always fulfill them immediately. In that sense, this process is a universal defense mechanism appropriate to this early stage of development. Within the course of normal development and with the help of a good enough caregiver (in the sense of Donald Winnicott, 1975), the child learns that she can be safe even if she’s separate from the primary caregiver and that the relationship with the caregiver is not threatened by ambivalent feelings.
   The help of the caregiver consists of containing the infant’s overwhelming feelings, metabolizing these feelings for the child, and feeding them back to her in doses she can handle. For example, a caregiver picks up and holds a crying infant and utters soothing words or sounds and verbalizes explanations of what she senses might be wrong.
   In cases where the normal development has been hampered, the child continues to experience difficulties in handling ambivalent feelings. The mechanism of projective identification becomes part of her habitual repertoire and will manifest itself within the context of interpersonal relationships.
   In the case of Pauline, she had a tremendous unconscious rage toward the mother figure. She projected this rage onto the youth care staff, particularly onto the primary worker, who started to experience great anger, irritability, and frustration in relation to this youth. These feelings had a flavour of strangeness because they did not fit with the circumstances of the life of the worker nor with her general emotional disposition. As well, part of the team was displacing their anger and frustration onto the primary worker, making her feel even more helpless and angry. This same dynamic was observed in the family where the mother’s role coincided with the one taken on by the primary worker.

2. In the team meeting, the primary worker shared this understanding of the youth’s dynamic and its impact upon her and the team. The consultant’s objective perspective, coupled with a clearly planned presentation of the process, allowed the team to accept a new understanding of the dynamics in which they and their supervisor were involved.

3. The “freeing” of the team from the above dynamics allowed for a more fruitful discussion of the complexity of the case, and led to the continued development of a new and more complete intervention plan. This plan had been initiated at the first meeting between the consultant, the supervisor, and the primary worker, and was presented and developed during the team meeting.
   

It was important not only to help the team eliminate behaviour or processes that were deemed unhelpful, but also to allow them to initiate something better. Without this, the risk that they would return to past patterns and responses was high. This understanding of their dynamics connected to the dynamics of Pauline and her family permitted these professionals to arrive at an intervention plan that acknowledged the youth’s need for particular attention and energy, and concurrently acknowledged the team’s capacity to respond.
This was done with the intent of creating a complementarity between the consultative and supervisory processes. It allowed all, including the supervisor, to take a step back and therefore return to the process of responsible and respectful treatment.

The practice of youth care in residential treatment settings is a highly complex endeavour. The inadequacy felt by a team finding itself unable to treat a youth in their care has been compared to these same feelings in a family unable to protect or help their child. Regular clinical supervision in such cases can benefit from the input of a consultant, whose practice is subjected to the dynamics of neither youth, family, or team. Depending upon the consultant’s particular background, she would bring a unique perspective that would be complementary to the supervisory process. This complementarity of consultation to regular supervision can be built in on a regular basis (e.g., weekly or bi-weekly meetings with the consultant) or on a more ad hoc basis.

Consultation becomes efficient in so far as there is a clear understanding of the roles and expectations of all parties involved and in so far as a working relationship exists between the supervisor and the consultant. Regular contact allows for this relationship of trust and credibility to also be built between the team and the consultant and thus facilitates the discussion of sensitive topics such as the ones presented in this paper.

1. The feminine form has been adopted to indicate supervisors, child care workers, and other professionals of both sexes.
 

Dionne, J. (1991). La supervision centree sur les operations professionnelles: un outil de gestion de la qualite des interventions. Revue Canadienne de Psycho-education, (2), 109-121.

Ogden, T. (1979). On projective identification. International Journal of Psychoanalysis, 60, 357-373.

Winnicott, D.W. (1975). Through pediatrics to psychoanalysis. New York: Basic Books.