The Browndale Therapeutic Family
An alternative model to the institutional
setting for emotional disturbed children and adolescents.
by Dr. Otto Weininger
Dr. Weininger is a clinical consultant psychologist at Browndale and Associate Professor, Department of Applied Psychology, at the Ontario Institute for Studies in Education, University of Toronto. During the Fall Term 1974, while on study leave, he was an Attached Staff with the Department for Children and Parents, Tavistock Clinic, London, England.
The following is the transcript of the address he gave to members of the staff, students and visiting scientists of the Tavistock Institute of Human Relations, the Tavistock Clinic and the Portman Clinic and Child Guidance Training Centre on October 25th, 1974, when he was the invited speaker at the monthly Scientific Meeting.
The Browndale therapeutic family1 evolved from two sources. First there was the groping towards more useful and workable ways of helping emotionally disturbed children, beginning with a group home institutional setting 20 years ago. And along with this practical learning went a deepening appreciation of the role of the family in the ego growth of children. Browndale began with sophisticated techniques especially adapted to the needs of the disturbed and institutionalized child and has gradually reached towards those simplest and most spontaneous of non-verbalized structures which underpin the nurturing family.
1 The Browndale program has 635 children in therapeutic family homes in Ontario and British Columbia; in Wisconsin, Illinois, Michigan and Arizona; and Holland and France; and about 700 families monthly in non-residential programs.
Today, the Browndale therapeutic families live in ordinary homes scattered in the community: outwardly, they are indistinguishable from their neighbours. Where Browndale homes once used to be distinctive by their intensity . ..". one had the sense of both children and staff pitched very high and the most therapeutic moments were felt by some to be those moments of dramatic revelation and intense interaction .. . the predominant tone today is that of the normal family. No more than four or five children, with a male and female surrogate parent, live in each home. (Some of the families are a little larger in some of the bigger farm homes). The children are as varied in age, sex and personality as they might be in any family. The daily routines and interactions with the community (from playing on the street with neighbourhood children, to shopping at the supermarket, to attendance at local public school) approximate the daily patterns of any family.
What is the most radical about the therapeutic family is simply that it is a model of what normal extended-family life, well and thoroughly supported by the community, might be. (Brown, J. L. 1969, 1974).
Our treatment pattern, then, goes back to our perceptions of the family functions. The family is the fundamental and enduring unit in society through which reality and meaning are communicated to family members. The literature points out that the problems children have are mainly the result of inadequate or over-reactive interactions with their parents. Further, we now understand that children may develop emotional difficulties as a result of child-parent reaction. Moss (1967), Robson (1967), have already demonstrated that the mother's feelings are, at least initially, under control of stimuli provided by the young infant; others demonstrate that the infant's smile may trigger the mother's instinctual nurturing feelings, and Robson (1967) shows that eye-to-eye contact between mother and child also has a positive effect. It is almost as though the mother needs to be recognized and welcomed by the infant in a way that makes sense to her. On the other hand, if the infant does not receive the care, the consistency of feelings, the satisfaction of needs from the mother, then he in turn will react with angry feelings, resistant attitudes, and perhaps physical difficulties. Spitz (1946) has shown very clearly that the infant may die if he is not provided with sufficient mothering, even though he has adequate food, shelter and warmth. The Robertsons' work (1958) shows that children respond with grief, depression and withdrawal if they are separated from their family for even as short a time as ten days.
The family gives shelter and care, passes on traditions and attitudes, and provides structure for the child's life. It is the foundation for the developing personality; when the child's emotional needs are under or over-gratified, the personality is distorted. One of the critical functions of the balanced family is the continuity of warmth, care and acceptance. Against this background, the child will be able to deal adequately with frustrations and anxieties. The web of consistently caring relationships is the safety net for the child's developing ego. His self-esteem, his courage for the high-wire of human endeavour, are nourished by his perception of that acceptance, which he understands through the tokens of food, physical care and reliable responsiveness. This is the parental gift: to enable the child to see himself asSafety net for child's ego an adequately developing person, neither overwhelmed by immediate frustrations nor encapsulated in his narcissistic feelings of omnipotence.
Means of allaying anxiety
As the child is enabled to mend his wounded ego (and those wounds arise necessarily from the non-gratification of immediate demands), he comes to view his parents as a source for supplies. This gradual transition from uni-centric omnipotence to identification with seemingly powerful adults is extremely important in the growth of the child, emotionally and socially. The child who does not see the adult as a source of supplies does not begin to identify with the powerful adult and sees himself as less than a person. Either he withdraws into depression, and/or he becomes hostile as an attempt to gain some foothold on feeling powerful. (Brown, J. L. 1969).
The symptoms of disturbed relationship may show up academically (the child may fail, underachieve, or over-perform); there may be direct acting out (delinquency, sexual deviation); it may be expressed socially (withdrawn, depressed passivity; hostile aggression). Whatever the mode or modes of expression of his problem (Freud, A. 1946), the child is nevertheless reacting to some pathological interaction within the family (Ackerman, 1958). He is learning ways of handling the familial conflict and subsequent anxiety through symptom production. The symptoms, however difficult for the child, are nevertheless his best means at the time of allaying the anxiety which would be overwhelming to his fragile ego. The child who cannot protect his ego by symptom production avoids family pathology by psychotic behaviour.
Once the family experience has proved inadequate in meeting the real psychological needs of the child, and the self-protective symptomology has been set into action, the family members become locked into disturbed patterns of relationship. These patterns are like an invisible wall between parents and child: the parents reinforce the wall, even when they think they are breaking it down, because the child now sees their efforts as counter-productive of warmth. Siblings, too, are caught in the web of interactions: it would be dangerous to their own precarious stability, to their own relationships with their parents, to do anything else. Rigidity, stereotyped patterns, concrete actions are the order of response. Hostility and rejection are the felt emotions. The disturbed child, seen in this context, does not need institutionalization. Above all, he does not need further isolation from wholesome community and family patterns, nor does he need a fragmented and specialized "treatment" of his "problem". What the walled-off child needs is to relearn and relive experiences in a family, where he will be able to satisfy the very early emotional needs without conditional acceptance and without hostility, and where he can test out his psychological drives in a setting which is structured, safe and understanding. This family should permit him and help him to regress when necessary, and will help him behave as a child of his age when and where he is able to ... but will not stress continued expectations which are beyond his emotional age level. This family will essentially help him to make use of his islands of ego strength and health, no matter how few they are, and build upon these islands, rather than concentrate on the pathology and symptoms which are so visible and so often entrenched (Brown, J. L. 1973).
Not a bundle of problems
Browndale, over the past eight years, has focussed on creating a substitute family that would fulfill these conditions. An absolute ground-rule has been that the disturbed child has exactly the same basic needs as any child . . . first and foremost, he is not a bundle of problems, but a whole child with additional needs (Brown, J. L. 1969). Going back to our analysis of the family functions, that means at its most basic level a provision of the tokens of care that flow from parents and are provided in an individuated way. Food prepared in central kitchens and distributed to "cottages"; bedrooms furnished by a central ordering office; or parenting provided by a merry-go-round of shift workers on rotating schedules, are not perceived by the child as tokens of authentic, caring parenting. Nor can a child care worker who has no continuing responsibility for the child and his well-being be perceived by the disturbed child as a reliable source of supplies.
In creating the surrogate family, therefore, it was necessary for Browndale to authenticate the full parenting role of the child care worker by removing him or her from the medical hierarchy. The surrogate parents run their home in a very real way: they are ultimately responsible for the child, they furnish and shop for the home, manage the weekly budget, save and plan for family vacations, deal with neighbours and merchants, fill the role of the parent in community events (parent-teacher nights at school, for example), and provide the structure, the daily routines, and cultural tone of the home. Like any ordinary parents, they call on community resources for relief; because they do not live in the houses, but work there from wake-up till bedtime, they hire community people to serve as night staff, cleaning help, or occasional babysitters. Like any responsible parents, they are on call to the night staff or babysitter at any time of day or night should a crisis arise.
The surrogate parent carries the sustaining relationship with the children in care. His or her daily behaviour with the child is in response not to the treatment dictates of a medical authority, but to the child's own needs. In interpreting the child's needs, and assessing progress, the therapeutic parent has a full range of professionals on whom to call. There are other therapeutic families in the community, with whom there are lively interchanges, visiting back and forth, and so on. There are the child care resource people . . . senior and experienced child care workers who act as visiting aunties and uncles to all the houses in a region, offering a wider spectrum of relationships to the child (as in any extended family) and offering support and advice to staff when called upon. Then there is Browndale's professional "resource bank": social workers, psychologists, psychiatrists, nurses, dieticians, who are on call 24 hours a day. The therapeutic parent, like any parent, decides when to call in professional help, and also decides whether or not to follow the professional advice . . . "because no-one in the treatment program has a better knowledge of the child and his needs than does the therapeutic parent who lives with the child and shares all his on-going daily routines and activities" (Brown, D. 1969).
Freed from rejection
Before the child can begin to explore and satisfy his emotional needs, a relationship of trust must be established. The child, who has been led to expect punishment or withdrawal from his natural parents, learns that in the therapeutic family he is freed from the possibility of rejection and the threat of punishment. In addition to the therapeutic parent's caring role, he also takes on the task of guidance and education, providing the child with models for identification so that he will be able to feel productive and effective in society. Importantly, the therapeutic parent involves himself with the child to an extent dictated by the child's dependency needs, not the needs or time convenience of the worker or the community (Brown, J. L., 1969).
An episodic account of an eight year old boy's day in a Browndale family may illumine the workings of the therapeutic family:
Johnny lives in a pleasant suburban home with four other children, ages 8 to 16, plus a dog, plus two young "parents". Steve, the head of the family, is 25 years old and in his third year with Brown-dale. He came with a certificate in business administration and a background of working as a volunteer with a boys' club: he was looking for work that would give him deeper personal satisfaction than he could find in business. Joan is 24 and a registered nurse. She has been a private duty nurse, caring for newborns and their mothers, has been a governess and has travelled. She came to Browndale six weeks before this episode.
8:00 a.m., during the summer holidays: Doreen, the night service staff, was in the kitchen helping the three youngest children find something to eat before Joan (the therapeutic mother) arrived to prepare breakfast. Johnny had asked for a "mushy" omelet made with mustard, ketchup and snack bits; he ate it drenched with extra ketchup and began playing jacks with Doreen.
Joan arrived shortly. She began frying eggs, coaxing Johnny to have some too, but Johnny was cranky now and "accidentally" threw a ball across the kitchen. Joan quietly placed it out of reach. Johnny then began an argument with Bob, an older boy in the family, about some toy trucks. Joan suggested they settle the quarrel when Steve arrived, and the squabbling faded away.
9:00 a.m.: The reason for Johnny's irritability became apparent when Doreen, a Browndale nurse, phoned to remind Joan of Johnny's dentist appointment that day. Given the message, Johnny raced around the room, yelling and crying, and then darted upstairs. Before Joan could reach him, he had locked himself in the bathroom, shouting, "I'm not going! I'm not going!" Bob, the older boy in the therapeutic family, proudly exercised his mechanical skills by getting the bathroom door open. Doreen arrived at this moment, and after being told about the crisis by the other children, went upstairs. Johnny, Joan and Doreen decided together to postpone the appointment until another day. Johnny, quieter but still tearful, came downstairs, wondering aloud whether he was getting sick. He decided he had to "take his tentature". Joan helped him, making soothing conversation until he regained his composure. His temperature was 98.8. "Does that mean I'm not sick?" Johnny demanded. Joan assured him that he was not sick but might want to rest a little anyway. Comforted, Johnny went off to sit in the living room, while Joan turned to an 8 year old girl who had been upset by Johnny's outburst. Laurie, the girl, gradually calmed down as Joan brushed her hair and put ribbons in it.
Dynamically, then: the therapeutic home provides a reliably safe environment physically (i.e. Johnny is not allowed to bounce his ball in the kitchen) and emotionally. Though Johnny is unable to face his dentist appointment, there are no recriminations and no withdrawal. In fact, he is able to find a way (the temperature taking) to reassure himself that he is still cared for, and the parent reacts responsively. It is the sheer daily-ness of the routines (the breakfast, the temperature taking, the safety rules, the hair brushing) through which the essential trusting relationship is established.
11:00 a.m.: Johnny discussed, calmly and realistically, his plans for the day when he will keep his dental appointment. Later, he joined an ongoing game of jacks with the other children and Joan. He insisted on using a damaged ball that bounced erratically. When Joan suggested he might have better luck with another ball, he flared up in anger . . . "Don't give me advice!" . . . but soon, quietly, switched balls. Johnny, who has difficulty in writing his own name and can't sit still long enough to concentrate on figures, was involved in this game for a considerable length of time, interacting with the other children, keeping track of the complicated score, and displaying great dexterity with small objects.Dynamically, then: the therapeutic home provides a reliably safe environment physically (i.e. Johnny is not allowed to bounce his ball in the kitchen) and emotionally. Though Johnny is unable to face his dentist appointment, there are no recriminations and no withdrawal. In fact, he is able to find a way (the temperature taking) to reassure himself that he is still cared for, and the parent reacts responsively. It is the sheer daily-ness of the routines (the breakfast, the temperature taking, the safety rules, the hair brushing) through which the essential trusting relationship is established.
Dynamically, then: through relaxed play in the family setting, the ego strength of the child is constantly reinforced. In the game of jacks, Johnny gained ego strength through his pleasure in play, his conceptualizing of number groups, his eye-hand co-ordination, his ability to play by the rules, and his self-control.
Late afternoon: After a family outing, Johnny came into the living room with a length of fishing line and a small crane. Steve quickly checked to see that there was no hook on the line, and went on to remark how hard Johnny was working on fixing the crane. Johnny responded immediately, and he and Steve went off to find tools to do "some hard work" on the crane. Equipped with screw driver and pliers, both set to work. Johnny told Steve exactly how tight to make a certain bolt. Steve responded by asking repeatedly, "Like this?" until Johnny was satisfied. When they got to a part that Johnny felt competent to handle, he took over while Steve watched with interest. When a screw dropped, Johnny casually "ordered" Steve to put one leg up while he, Johnny, searched on the rug. Steve just as casually obliged. When Steve was called away to cut the meat for supper, he asked Johnny if he thought he could continue working on his own. Johnny thought he could, and did.
Dynamically, then: by constantly bolstering the child's real areas of strength, normalcy and competence, the therapeutic parent helps him replace his earlier hurt and suffering with real em isfactions, and then growth. In this instanc feeling of adequacy, sorely tried in the mon ive dental appointmet happily reinforced.
After dinner: Johnny and Steve walked to the drug store to get someme ointment for another child at Johnny also bought a new leash for the family dog and was anxious to test it out. Steve had to go out again on another errand but agreed that Johnny should walk the dog, with specific instructions on how far he migh go. Before long, Johnny was running down the sidewalk with the dog. Joan appeared at the door commenting favourably on the new leash. Before going back she gave Johnny new instructions on how far he might go. When she came back out again a few minutes later Johnny had strayed past the boundaries. Steve, just returning and hearing from Joan what was happening, quickly Johnny inside and explained that he was to follow the rulesJoan set in his absence, even if they were different from his own. He suggested, and Joh agreed that Johnny often heard only what he wanted to hear, It was agreed that Johnny could go outagain when he felt he could stay within the set limits. Johnny argued briefly, but without mucu energy Shortly afterwards, Steve noticed Johnny back at work on the crane and came over to ask if any help was meeded. Later, Johnny put away his toys. Steve took him to the kitchen for a bedtime snack. Joan asked if Steve could tuck Johnny in as she was busy with Sue. Steve piggybacked Johnny upstairs.
Dynamically, then: Johnny takes the reprimand from from Steve calmly. He is able to see that there relationship is not diminished, though he will not be allox3ed to break the rules and his therapeutic parents will be supportive of each other in maintaining the ssecurity of the children. Through participating further in the work on the crane, and through feeding and loving physical handling at bedtime, Steve reassures the boy that he, Johnny, will not be able to "spoil" the good things and continuing acceptance offered by the family.
Often the child's growth is accompanied by recognition of why he has had troubles and symptoms: along with this may come a ventilation of hostility, great demands for reassurance, and much physical affection. Patience, understanding and endurance are essential on the part of the therapeutic parent. Mainly, the parent has to act like a person and communicate with the child by whatever means are available. Perhaps all they can do at first is to sit on the floor and eat marshmallows, or lie on the grass and feel the warmth of the sun on their bodies. It is the experienced communication between the two people that begins the long, hard road back to life and livingness. It is the "result of the reflections he gets back from the persons who care for him" that "he begins to get not just an image of 'I exist as a self but also 'I have value', if the persons who care for him reflect that value back to him." (Brown, J. L. 1969)
In the therapeutic family, the child becomes responsive, self-reliant and creative. He no longer lives within an isolated nuclear unit, but becomes aware of the interdependence of one family member with another, of one family unit with other families in the community. He has 'uncles', 'aunties' and 'cousins'. He is sure that his needs will be satisfied by a variety of people, all desirous of helping him achieve an effective, satisfying life. Not to be underestimated is the therapeutic effect of the other children in the family. By painstakingly careful grouping, by grouping according to varied strengths and not according to similar pathologies, the siblings are made part of the therapeutic unit, exerting a strong normalizing pressure on each other.
It is crucial not to be deceived by the apparently easy normalization of the life style. It is not just the mildly affected youngster to whom this therapeutic family is adapted: On the contrary, many of Browndale's children are among the most severely disturbed minority of disturbed children, children who have often been refused treatment elsewhere. Because the therapeutic family is so de-institutionalized, because at every point it reinforces the child's "islands of ego strength", there may be hours in every day in which no pathology is in evidence. Nevertheless, carefully built into the family routines are subtle and complex structures, well understood and integrated by the child care staff, to make this open setting at once safe, orderly and constructive.
Staff respond sensitively
When the therapeutic parents turn to the professional resource bank to check out their progress (they ask questions like 'How can I cope with the children's rivalry?'; 'Is our family feeling safe enough so that this child will feel comfortable investigating his earlier hurt?'; This girl is 10 years old and likes to be fed her meals; I think this is O.K. but I need your help to feel secure about it'; or 'I think this child needs extra help to be able to interact with the therapeutic family . . . he's too far out; I can't reach him') the professionals help the staff to respond sensitively to the child's needs, while at the same time trying wherever possible to normalize the child's lifestyle rather than focussing on pathology. When a therapeutic parent gets sidetracked into dealing with fragments of pathological behaviour, the professional's support helps to re-focus him quickly. The "mother" and "father" of one Browndale family consulted a psychologist in the resource bank about severe bedtime difficulties with a ten year old boy. Both had become absorbed in the problem of how "handle" the child's tearful ta trums and near-violence at be time. It soon came to light th the boy dreaded sleep because it heralded fearsome "monster" nightmares.
Dynamically, then: The psychogist pointed out that the therapeutic mother, by putting the be to bed herself, was inadvertent reinforcing the retaliatory Oedip theme of the nightmares. The father was advised to take over the the bedtime routine himself, with much physical gentling. The nigh mares, rather than being airily di missed as "just bad dreams" or laboriously analyzed for the boy benefit, were to be dealt with by affectionate reassurance that the father would let no harm come 1 the boy, and that the boy's wholness was important and valuabe to the father. Within a week, the parents were able to report that the bedtime difficulties had var ished.
This is the essence of normal zation: the professional support and strengthens the parents' wil ing capacity to tune in to th child's deepest needs. The treal ment then flows, not primaril from a detached hour in the da or week, but from the therapeuti parents' informed and tender re sponsiveness, woven into th hourly fabric of family life. Th professional resource bank peopl are always available for an emer gency, an inquiry, a call invitin' them to visit or to have lunch, o for a telephone talk about one o the children in the family. The re source bank people are prepare* to discuss or visit a particula child and to help make plans fo children in treatment. They alsi make planned regular visits fo consulting, exploring therapeutii family interrelationships and trans actions, and assessing the child': individual emotional, social am academic growth.
Children with every type anc degree of disturbance, including the physically handicapped, the
mentally subnormal, the psycho-neurotic and the severely disturbed and so-called mentally ill children, are taken directly into treatment. Each child is assessed by the professional staff and placed as quickly as possible into a therapeutic family. The children in the family range in age from 2 years to 19 years, and thus act as older and younger siblings to the new child. His placement in the therapeutic family will generally be determined by the kind of problems he has, his age, and the area (rural, or urban) from which he comes. We try to keep children in the milieu that is most familiar to them, rather than to give them any further unnecessary jolts by placing them into areas which are totally unfamiliar to them. Separation from their home is enough of a jolt.
Within the therapeutic family, the child is provided with the opportunity to learn and experience, to relearn and re-experience the very difficulties and interpersonal problems which fostered his disturbance in his own family. Unfortunately, many of our children (64 per cent) have been separated from their families at very ear|y ages, and have an unusually distorted and peculiar view of family and family relationships. These children try to deny the existence and substance of their own and other family relationships and ties as well as what we call the "family reverie", which acts to hold and contain the child to his relationship with the therapeutic parents. The special family interrelationships of caring, and listening provide this holding relationship for extremely disturbed children.
Since the child lives with therapeutic parents who have been helped to respond to his needs without punitive reactions, the child is freed from overt feelings of rejection and punishment. The therapeutic parents gain understanding of how to help the child express his feelings through action, through play and verbalization; the therapeutic parents are helped to understand the child's unconscious patterns of behaviour in order to help the child begin to explore his sources of anxiety and strengths. The child, rather quickly, begins to gain some feelings of emotional closeness and warmth as a result of the care, limits, and responsiveness to him as a child. This is, to us, the beginning of a family reverie — a relationship which acts as a holding agent, for the child to view and contemplate his feelings without threat of rejection, of smothering, or of indifference.
The child, in turn, learns to further and deepen his tie to his therapeutic parents, and then to further experience deep pains and unconscious wounds. The strong relationship between the child and his therapeutic parents allows him to explore these wounds, and should a program of individual treatment be necessary, then a trained therapist from the professional resource bank will begin to have visits with the child. His therapeutic parent is included in the therapy sessions, particularly if the child wishes him to be. We think that at first the child is afraid he may lose or weaken the tie between himself and the therapeutic parent if he sees the professional therapist alone. Within time, and through interpretation to the child as well as to the parent, the child usually comes to see the professional alone. However, the therapeutic parent is given understanding of the session, and if necessary some direct advice. These sessions may last for a month on a twice a week basis, or they may continue for several months. At other times, it becomes necessary for the professional to work with the child and his therapeutic parent and to help them both understand the complexity of the child-therapeutic-parent transference relationship they have entered into, and to which aspects they are both responding with their old unconscious "own family" dynamic transactions.
The child and therapeutic parent also experience thereapeutic families and become aware of the interdependent family upon another. The families do not suffer alone or in silence. they are not isolated necular families; and by not being necular they are able to gain emotional reassurencnce, satisfactions, and just plain baby-sitting or work fromother families. We are impressed by the way in which tl family can offer support to each nuclear unit and prevent disasters which would no do active intervention from professionals.
The therapeutic fan usual types of home j have said, and when the child attends the n munity public school.
It is noteworthy th per cent of the childr to Browndale have : culties. They are unal they are unwilling to at or they have been refi sion to schools beca; tinued destructive an< behaviour. Upon ad Browndale, these chil< do not attend any kin Gradually, they atten oriented developmenl and later on they atter schools. The develop gram is directed to p child with interper dependency satisfacl strong child-teacher These, we think, allow mobilize primitive cor his ego and gradually functioning so that su as comprehension, ji tention, visual-motor gradually come into pi is encouraged to use which are symbolica his level of developn his development prc the art materials are complex, with acade being interwoven wi His learning proceeds mental fashion with c medium for ego grow
Essentially, then, we assume that the therapeutic parent is the most significant person in the treatment program for the child. He cares for the child in all respects. He is essentially the child's parent. He has the added responsibility to help the child discover himself, to understand some of his difficulties and to find possible solutions.
The therapeutic parents bring a wide range of interests and ideas to their families, but mostly they come because they want to involve themselves in a deep and significant way with children and because they have the desire to extend their own understanding
about themselves. The therapeutic parent undergoes a growing and developing process along with the child; and opportunities for personal growth are made available to this person. We usually find that as the child develops, the therapeutic parents feel the need to understand the impact of the child upon themselves and of themselves upon the child. To ask for this "feeling" to come earlier is wrong, we think, or to demand that the therapeutic parent be involved in such a program without his own perception of this need, is wrong for us as well.
We think that treatment for the emotionally handicapped child in a therapeutic family in an ordinary community setting, encourages and provides the avenue for emotional growth and development. The child begins to sense a freedom to explore his world and be curious about himself, for his therapeutic family has provided him with safety (Routine, limits and anchor points Brown, J. L. 1974), structure (relationships) and tenderness (emotional gratification). The child can look out from himself, to his family, to his world, and begin to realize and recognize that there is now an enduring stability for him in how he perceives and is responded to.