©2019 CRRES model of therapeutic assessment Hilary Hickmore

CLIENTS' USE OF SYMBOLISM

Samantha and the tombstone

Background

Samantha was 14 years old.  She had been excluded from school, and was in her 2nd children’s home, after disclosing abuse towards a younger sibling 2 years earlier.  She behaved in a loud, brash, shouting, bouncing, over energetic manner, answering back to adults who gave her instructions and being highly disruptive both in school and in her residence.  She was intensely fidgety and seemed hyperalert all the time, and did not sleep well.  Her keyworker asked for a therapeutic assessment, wishing for some guidance as to what might be most concerning her and affecting her day to day behaviour.

 

The session

When we met, after explaining about what the session was for and that I would be liaising with her key worker after the session, I offered Samantha the full set of craft materials and miniatures, wondering if we might make something that showed how she was feeling in her life.  I chose an unstructured and non-directive task, given her current difficulty with taking instructions from adults, and included the subtle invitation that we could do it as a shared activity.  Her energy changed from bouncing effervescence (which felt almost too big to be confined in our small room) to still focus.  After scanning the materials, it was as if she had something waiting to be made.  She started immediately.  For the first half of the session she constructed a carefully crafted kitchen and dining room scene, with figures who may have been her family – she did not say.  The mother figure set the miniature table with cutlery, plates and cups.  The children figures were sat to watch the tiny TV. 

She placed the father at the table.  All was quiet.  She moved the mother to place a cooking pot on the table – at which point Samantha took up the father figure and started shouting a lengthy tirade of threats and abuse, to which she stood the mother back to the edge of the room.  Moments later she lunged the father figure forwards and  swept everything off the carefully laid table top, upturning chairs, tables and sending lamps and miniature TV flying from their place.  She hid the children figures in the corner.  She imitated the mother sobbing and apologising.

Without leaving space for me to comment (- it seemed enough for me simply to be there, with her, witnessing, observing and accepting) she packed the scene away.  I took an obvious deep breath and exhaled slowly, showing the contrast of calm in our room that day, stating “things must have been very hard for that family…”  and, after a pause, “I wonder what it was like to be there when that sort of angry explosion happened”. 

Samantha ignored me completely and turned to the stack of large coloured paper.  She carefully extracted a brown sheet, chose some chalk pastels and began to draw – with great focus and concentration.  She drew a large tree, with considerable care, under which she shaded in a grey ancient looking tombstone.  On it she inscribed the letters R – I – S , before proceeding to add detail to leaves.  I waited and watched until she sat back, satisfied that it was finished. I asked her to tell me about what she had made.  She announced matter-of-factly “Rest – In – Shit”, as she pointed to the tombstone.  She then went on to say that she messed the bed most nights.  She didn’t do it on purpose.  She didn’t know why it happened.  The care staff were annoyed about it, and after checking her bed in the morning, called loudly down the stairs to her in front of the other residents to come and sort her filthy bed.  I commented on that sounding like a difficult situation to deal with, at which point Samantha looked at the clock and said that her key worker would be waiting, signalling her wish to finish the session.  It was 5 minutes to the end of the time we had allotted, so I started to offer a summary, aiming to round off the session comfortably.  Samantha interrupted with a question about whether she could come again.  I said if she would like to then I would ask about whether that could be arranged, at which point she jumped up, said "bye" and marched energetically out of the room.

Follow-up

When I was able to speak with her keyworker, 2 days later, he had been surprised that she had sustained working in the session for almost the full hour.  It became clear that the domestic violence scene she enacted in the miniatures was in line with his understanding of the sort of scenes that used to occur in her family home, along with more violent acts.  We both took from the session that those experiences were still very much at the forefront of her thinking, and that would perhaps explain her over-activity, constant need for noise and distraction, heightened vigilance and night-time wetting and soiling.  She was likely to be living each day in a state of high arousal and profound stress.  She needed help to find a calmer state, and that could be a useful focus for staff to consider.  We talked about what some options might be. 

We considered how this single meeting may have offered her a chance to check out how I would respond to some small indication of what she had been through, and that there was likely to be much more that regular creative activity, therapeutic play or non-directive play therapy could assist her in working through.  She had to date refused to attend regular sessions with mental health services, and had joined the session today on condition that it was a one off assessment.  Hence her keyworker agreed to discuss the option of further sessions with her planning team.

I then shared information about the RIS tombstone, and queried about the social humiliation associated with the way some staff may be dealing with the soiled sheets.  Her keyworker was concerned about the approach Samantha had described, and agreed to consider with house staff a clear agreed means of addressing the problem, whilst also helping them understand that the behaviour was coming from a place of intense anxiety and traumatic stress, and hence not something she could be seen as responsible for and treated punitively for.

On review a month later, Samantha's keyworker reported on a marked shift in the approach the care staff were taking, putting into action a more nurturing approach.  Her bedroom had been improved to help it feel cosy, with her own choice of soft furnishings and bed linen (which was changed when needed subtly), plus she had new toiletries and nightwear.  A second member of staff was asked to take a keyworker roll with Samantha, making sure that there was someone on shift more of the time who took particular care to get to know her, to connect, whilst doing creative activities, and lead her in finding her calm state. 

 

Reflection

The role of my assessment here was to enable Samantha's support system to base their approach on an improved understanding of Samantha's experience, emotional state and perspective, none of which she had been able to communicate to them directly in words.  The variety of materials and a non-directive style allowed both the opportunity for her to enact a scene that mimicked real life, as well as give information around a sensitive subject using richly creative symbolism. Such insight helped staff see the vulnerable stressed child beneath all the noise and powerful energy, fostering a more empathic, compassionate approach and assisting them in offering her their emotional availability for genuine connection.