FANTASY AND DELUSION...CHILD AND YOUTH CARE TALK

   

There was Blom (flower) and Mielie (a head of maize}. Blom spoke into the one ear and Maize into the other. Mielie said "Just go on and do it!!" Blom said "No! no!!  - that's not you. It's not right".  

Full psychiatric evaluation showed no schrizophrenia. Sometimes Mielie won and sometimes Blom. Given a chioce, we would ask "What does Blom say?"  Where do these id, and ego and superego voices come from ...Ancestors?  Over time we all knew that Blom and Mielie were real heard voices for the boy. 

She was sat with a group of girls in the foyer. Normal girly talk complete with teenage giggles - all very light-hearted. It was comfort for her. She needed this. 

I stood at the tea-wagon. She and two others sat facing it. The rest of the group were on the other side of the coffee table and facing her. 

I say it was what she needed because she was grieving the tragic death two weeks previous of her 21year old boyfriend Len. It was a serious relationship with the promise of marriage when she turned 18 - which was soon.

 Suddenly her eyes fixed on the main door of the facility which opened up into the foyer. 

 "Len! Len! It was a deeply emotional cry. Her body stiffened, her eyes opened wide. She twisted. her body and eyes tracked from the main door to behind her and up the stairs to the girl's dormitory.

"Len! Len!: Then tears,i

'Did you see Len?" one asked. 

"It was Len. Len came. He went up stairs.

 Not one girl questioned it.

When the news came from the hospital that their mother had died, we followed our standard procedure. We asked that the body not be removed until the two were taken by the child and youth care worker to the hospital and the bediside of the mother's body . They took flowers., placed them on the mother's chest, kissed her forehead took her cold hand and said their goodbyes.

 They had to experience the reality of her passing.

Time elapsed as we waited for the family from Zimbabwe. It was a full funeral service attended by the children, with the coffin present. They again had flowers to put on the coffin before it was wheeled out.

 She was cremated and the relatives took the ashes to Zimbabwe .

 Telephone calls were made to the two children from Zimbabwe. On more than one occasion they told us, The Zimbabwe family had said "Your mother is safe with us." Meaning the ashes were urned and on the shelf above the frireplace awaiting internment.

From snippets of conversation the child and youth care worker joined the dots. The two children were living with the delusion that their mother was alive and living in Zimbabwe awaiting an internment  At the hospital, they thought that the mother was just sleeping... she looked like she was sleeping. The funeral was just something we all went to as a Home.

Hasty footwork had to be done. The Zimbabwe relatives were persuaded to bring the ashes to Johannesburg. An internment was arranged. The two children held and placed the  urns into the wall of remembrance.  They were told to tell us all what they remembered about their mother now gone forever. The cubicle was sealed with a plaque. They helped. There were tears....at last !!! Good healthy tears.

A friend brought her to the office "She has not been at all well" she said. "It seems like she's in another world...like she's not connected."  She had asked to see her children.

"Let's talk a bit while we we call the children"...structural delay.

Fear struck suddenly, looking towards the door, "They're coming! They're coming!"

"Who's coming?" 

"They are coming. They are coming to suck my blood and take me away. Only the blood of Jesus can stop them. They are coming."

 "I can call upon the blood of Jesus and chase them away" I said.

 Putting my hands without contact around her head, I said the words I thought were needed. "Out...Out In the name of Jesus.

She stiffened like a board, like a plank of wood, resting her neck on the chairback and her legs outstretched in front of her. Then she slumped into a coma. like state.

The resident nurse was called and the ambulance. Vitals were taken. They were fine.

 The Psychiatric ward did wonders and after three days she was discharged.

At the back of this episode was a true story which had an indelible effect on my practice.

A woman in a psychiatric facility for some or other condition refused to eat. This was unrelated to her diagnosis.  It didn't matter what they brought her, or what they did, they could not persuade her to eat. The doctors and the psychologists did all they could. But...Nope!!

 She was fading, wasting away and would surely die.

 A young intern was the only one who had been part of the treatment procedures asked to be allowed to try. It was agreed. "OK, you try."

he went to her bedside . She said,"Im not going to eat. They are trying to poison me".  '

"You're right he said. They are trying to kill you. They're not trying to poison you. They want yo to starve to death.'

That evening, she ate.

"What did you do?"

Our best qualified professionals tried and she didn't eat. What did you do?"

'I needed", he said "to step into her world for a moment...into her reality. Her fantastic delusion is her reality. I agreed with her reality as a start and worked from there". 

WHISPERS IN THE STORM - A VOICE FROM RESIDENTIAL CHILD AND YOUTH CARE SERVICES IN SOUTH AFRICA

Amidst the cacophony over the last few weeks in the social media on salary issues,came a lone, somewhat quiet voice from a child and youth care worker in a residential setting. 

Listed were four comments made in the best interests of children and young people.These whispers amidst the storm need to be heard.

Broadly, child and youth care workers in residential settings tend to feel swamped by what they experience as a deluge of focus on community-based care services..... dominantly,.. Isibindi. The comment is that they seem to be forgotten. Certainly social media is seemingly quiet from the non-governmental sector.  Yes, passion and love of the profession and the children comes up time and time again, But, then, "If  you want to care for children, don't expect to be well paid." I hear it often, "It's a vocation, a calling, not a job."

The whisper in the social media, did not mention salary.

The first whisper was that residential services do experience instances of "inappropriate placements" of children "for shelter or convenience" when more appropriate placements could or should have been made. The comment went further to say that this meant that the service's programs and/or system in those instances did not meet the needs of  those children.

I used to call those placements "pap en pampoen" (porridge and pumpkin) placements. In my first appointment to a residential service, a calculation based on an analysis of  the situations surrounding the children was that well over 40% of the children didn't need residential care. - some other community-based, family-based solution could be made. As a non-governmental organisation it was possible to orchestrate, with some success, a program of disengagement and family support for most of those children especially as the old Child Care Act required that there be at least a 6 month period of "after care"which was frequently undertaken by the residential facility itself. When, in my second appointment, 16 children were discharged at one time, I cried. Not because I would miss the children (as the staff thought) but because of their deinstitutionalisation.

The issue of removal and placement of children in alternative forms of care , especially residential facilities is well explored in a classic book by Anna Freud and others, Beyond the Best Interests of the Child  (the Free Press NY 1973 ) - note the year!, ...and the issues of removal and placement still persist. 

Four placement considerations expressed in this classic work are worth mentioning.
1. Removal and placement is a Moral Issue--it is an ethical decision. Is it ethically right? This means, equally, that an admission decision is an ethical decision.
2. Removal and placement decisions are based on the "least detrimental alternative".  I quote "Placement should provide the least detrimental available alternative for safeguarding the child's growth and development"   In South Africa we use the term "least restrictive, most empowering". 
3.Residential placement is a Last Resort. It  only morally defensible she says, in instances when the child faces "irrevocable harm" 
The concept or criterion of "irrevocable harm" applies only when NO other form of intervention would prevent PERMANENT damage to the child's psyche. 
4. Lastly, there must be advocacy available for the child's own view on removal, placement.and program. Adults view of ethical placement, she says, frequently differs from that of a child.  Such an advocate for the child must be a person who can express, for the child, its understanding, perceptions needs and decisions. 

There was this whisper of residential services admitting children and young people in order to maintain its numbers. If subsidisation is based on a "heads on beds" calculation, it can be enticing to keep the numbers up no matter what. - enticing to entertain placements and prolong stays.

The final whisper shouted that a "one size fits all" system and program was not meeting the needs of inappropriately placed children.

It has been my experience that admission criteria in some residential facilities have either not been established in policy, or is given to the facility from "above". This inevitably leads to inappropriate placements. On arrival in my second appointment in a residential care facility, I inherited a very simple admission policy. It had no criteria for admission at all. The policy was: " We don't refuse any boy " Well that certainly kept "heads on beds" but couldn't be defended ethically. sounded good, especially from the church perspective. It meant that the young person had to fit the program, rather than the program fitting the child.

This is what the whisper was shouting. Whats the point of having an Individual Development Program (IDP) if the system is not based on the individual..? The motions are gone through as required but the practice in the life-space, on the ground, doesn't always match the intention 

I always thought that the "hot house" for the growing of child and youth care practice was to be found in the residential facility. I thought that as the Grand Prix leads the way for the improvement of passenger cars, so residential care leads the way for child and youth care in any setting, especially community- based care. Isibindi as a model, has proved me wrong. We have a lot to learn from this now nationally and internationally accredited model of professional child and youth care .

It is time, I think, that we start again to rethink residential care and grow a South African indigenous model of best practice  for residential settings . One that can be rolled out, adapted as contexts require, and provide high quality developmental treatment to children and young people who would otherwise experience irrevocable harm,

Let the whisper become a shout for excellence in South African residential care.