Child and Youth
Consultation as a complement to the clinical supervision of youth care
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.
Support needed by youth care workers in the
exercise of their functions
Support needed by youth care workers in the exercise of their functions can be divided into four categories: emotional support, instrumental support, conceptual support, and support of clear institutional guidelines.
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
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:
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:
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
The authors, inspired by Dionne (1991), make the distinction between clinical supervision and other aspects of supervision as outlined in figure 1. The two aspects are artificially disconnected in that one cannot supervise, for instance, an absent youth care worker, nor will a worker seek out less organizational, more clinical supervision without some measure of overall trust having been established.
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:
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.
Case example: Pauline
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
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.
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:
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.
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.
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.