Summary / Abstract

Title: Secrets and security: knowledge and the confinement of adolescents

Synopsis: Adolescents in a psychiatric unit may go through periods of crisis. This paper analyses crises occurringat a psychiatric adolescent unit over a period of 4 months. These crises were found to have a circular pattern and each stage inthe crisis connected demands for security with demands for the passage of information. Four patterns of crisis were identified,named as ambivalent, avoidant, chaotic and rigid. In each crisis the transferred information was found to be descriptive of theadolescent's relationship with adults important in his or her life. Each crisis could be understood as an attempt to change theadolescent's relationship with these adults. adolescent, secret, crisis, adults, security, pattern, crises, demand, psychiatry, confinement, staff, stage, Goldberg, avoidant, mother, rigid, social relationships, disclosure, staff member, professionals, paper analyses, family meetings, second stage, community meeting, transferred information, circular pattern, surveillance, attachment behaviour, social process, physical security,

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journal adolescence 1996 19 583 594 secrets security knowledge confinement adolescents david goldberg adolescents psychiatric unit go periods crisis paper analyses crises occurring psychiatric adolescent unit period 4 months crises found circular pattern stage crisis connected demands security demands passage information four patterns crisis identified named ambivalent avoidant chaotic rigid crisis transferred information found descriptive adolescent relationship adults important life crisis understood attempt change adolescent relationship adults 1996 association professionals services adolescents introduction psychiatric units adolescents characterised routines day week structured regular meetings activities steinberg 1982 edgar 1990 frankenberg 1991 changes routines occur negotiation discussion e g rapaport 1960 mason 1989 routines disrupted prior agreement crisis prompted staff crises expected adolescents present crisis adolescent units timing recurrent crises predicted easily years central government demanded greater care control adolescents crisis health advisory service 1986 fully approved specific ideology institutions holding adolescents crisis related disagreements professionals hold knowledge confinement adolescents prison social service education psychiatric professionals adolescents move different institutions suggesting placement depend external factors needs adolescent malek 1991 management adolescents crisis likely differ institutions adolescent units vary philosophies admission criteria steinberg 1982 parry jones 1990 crises institution evolve differently paper analyses consecutive crises period 4 months adolescent unit author staff member 1990 92 describes crises attempts relate ethos management adolescent unit crises understood terms philosophy ethos unit particular time setting described methodology patterns crises elucidated case description reprint requests correspondence addressed d goldberg adolescent service pathfinder mental health nhs trust 32 york road battersea london sw11 3qj u k 0140 1971 96 06058312 25 00 0 1996 association professionals services adolescents 584 d goldberg setting adolescent unit sited villa outskirts large suburban psychiatric hospital periphery health authority area provided funding regional adolescent unit oldest series units britain provide inpatient psychiatric care adolescents villa poor state repair held highly visible weight relieving braces referrals came wide geographical area range presenting problems marked referrer concern adolescent psychological state adolescents classed emotional mixed emotional conduct disorders significant minority psychotic eating obsessional compulsive disorders unit medically led psychiatrists taking lead negotiating admissions nurses largest staff group controlled day day running unit teachers worked largely site neighbouring villa social workers worked mainly family therapists adolescent admission organised family meetings pattern work responsibilities described steinberg 1986 unit organised ethos timetable ethos openness self help co operation ethos explained adolescents time admission re enforced community meetings 5 day week timetable adolescents returning home weekends emergencies adolescents attended classes mornings twice daily community meeting therapeutic groups family meetings meetings key workers afternoon social activities organised staff timetabled late afternoon evening adolescents admitted unit thought suitable alternative adults adolescent stated time crisis admission proceeded adults passive consent adolescent came agreement unit staff criteria discharge formally agreed goldberg et al 1992 criterion discharge initially understated unit staff felt unable ensure safety adolescent two parallel structures unit main organised predictable routine meetings activities second managed episodic crises day three members staff called direct management crisis member institution staff adolescent declare crisis crises met escalating series interventions immediate problem solving emergency community meeting take precedence meetings urgent family meeting crises prompted adolescent concerned follow required routine staff felt sufficiently perturbed adolescent safety disrupt routine unit potential crisis built adolescent stay unit adolescent moved home unit safety unit lock doors night occasional minutes hours crisis adolescent expected return home weekend method study starting work adolescent unit child adolescent psychiatrist training author found change appointments short notice 585 secrets security puzzlement regular routines institution frequently interrupted crises prompted study author time emotion involved managing crises feeling like spectator impromptu drama uncertain happening knowing meaningful feeling unable influence events scenario come conclusion sensing show familiar wanting repeat performance attempt manage understand crises author kept systematic record series consecutive crises 4 month period notes written immediately crisis elaborated descriptions crisis collected staff adolescents compared author descriptions first month detailed descriptions prepared descriptive categories developed two sensitising concepts developed framework grounded methodology developed glaser strauss 1967 widely north american studies health care e g morse 1989 sensitising concepts words refer accurately relate precisely defined blumer 1979 sensitising concepts connect empirical evidence directly possible words describe two concepts knowledge security dominated data collected first concept knowledge referring information transferred sought time crisis constituted knowledge necessarily explicit referred secret second concept demand increased decreased security adolescent security request demand change rules unit applying adolescent involved temporary change rules unit applied adolescent data collected examined see relationship knowledge demand search information security changes demands confinement general appeared tacit bargain unit provided safety adolescent exchange information ethos structure admission process re interpreted light concepts records crises analysed relating time transfer knowledge changing demands security revealed series patterns demonstrated relationship secrets security information flow rules residence passage information unit rules residence described analysis series crises demand staff adolescents flow information forum required different type information style presentation focused twice daily community meeting nurses hand meetings three times daily ideology conscious attempt supported sociological evidence bloor et al 1984 ensure relevant information adolescents working therapeutic unit shared members staff involved author noted decisions effected staff member involved instance minimum number staff dealing family three takes three make decision joke staff members adolescents living unit 9 am 7 pm prescription talk 586 d goldberg situation act manner designated staff bad sad mad rarely spoken frequently referred presumption adolescent situation improved able talk concerns talking seen substitute unacceptable action referred acting tell worried won t need march saying t think staff member exhorted adolescent corollary ethos free flow information staff requirement adolescents inform staff worrying admission process linked demand information requests safety security adults adolescent requested admission grounds treatment occur outside hospital exchange providing increased security admission agreement negotiated change adolescent discharged adolescent agreed passively follow rules residence e g home weekends attendance groups resulted paradox adolescent broke rules discharge follow contrast focus flow information unit hierarchy external unit appeared dominated secrets withholding information members staff power failing provide effective provision financial resources unit instance areas health region demanded adolescent unit provide care adolescents crisis funding precarious budget known adolescent unit due close date announced regional health authority lack care visible poor state building adolescent said accusingly don t care place slum look crisis scenarios staff unit expected series crises adolescent stay belief disturbed disturbing adolescents disrupted social relationships reproduce unit rapaport skellern 1957 goldberg clery 1993 prompt crisis seen opportunity therapeutic intervention members staff state tenet crisis opportunity change features common crises documented study crisis called adults possibly prompted adolescent peers family appeared correlation calling crisis level adolescent distress instance adolescent distress long time deny problems crisis declared adults crises appeared consist stages first stage marked adults declaring crisis handing responsibility adolescent security entire staff group second stage members institution physically protected adolescent third stage protection confinement relaxed fourth return status quo crisis circular pattern related demands security secrecy disclosure information crises marked two beliefs held participants firstly information needed passed adolescent adults crises resolved secondly adolescent required increased surveillance search information 587 secrets security crisis adults adolescent holds secret refuses reassurance b adolescent discloses information demands security adults increase confinement adolescent d status quo c information partially withdrawn security withdrawn adults reassured figure 1 ambivalent pattern four different patterns crisis emerged pattern related search information demand security patterns characterised ambivalent avoidant chaotic rigid terms describes adolescent relationship knowledge secret ambivalent pattern figure 1 onset marked crisis adults adolescent times adolescent deny crisis acknowledge distress unable tell adults happening say secret say resolve crisis reveal information adolescent refuses accept verbal reassurance adults physically confined short time adult power adolescent partially totally tells enacts secret words action second stage enaction refers idea adolescent acts prompt adults believe know adolescent intends communicate similarly adults effected change physical verbal assurance followed adolescent disclosing person socially distant powerless disclosure heralds start third stage adolescent presses adult pass secret abuse adult making assurances absolute confidentiality disclosure adolescent demands privacy security locked side room partial disclosure adolescent fearful extra security demands liberation accusing securing adult imprisoning sense imprisoning decreases secret denied crisis return status quo crisis case 1 l 15 year old girl carers children home called crisis unable tolerate girl cutting l said desperation reached high pitch temporarily resolved sense hopelessness cutting feeling cut soreness seeing trickle tears blood feeling relief lives l mother repeatedly left l older sister aged 16 days end went drinking binges sisters taken local authority care l 5 rehabilitated back mother 10 l continued feel responsible mother drunkenness l periodically withdrawn truculent unit prompting crisis staff gave increasing hints nurse allocated care sexually abused abused weekends returned children home 588 d goldberg denying sexually abused time give details l agitated partial disclosure attempted retract said height conflict disclose explicit details name abuser start cutting demanding left die mobilised staff care guard l gave deadline tell name abuser deadline approached distressed staff said right time disclose abuser name series events precipitated crisis alerting staff adolescent distress events l learning mother childhood abuse closure children home telephone call mother drunk weekend meeting abuser crisis l gave details female nurses agitated deny details direct questioning i abused i abused disclosure expressed suicidal ideas cut time staff convinced abuse acted suicidally staff responded increasing physical security relaxed agitated let screamed pacing room wide open door disclaiming abuse resolved crises staff believed l dilemma allow abuse continue feel responsible mother drinking name abuser felt alienate mother case crisis precipitated adolescent physically secure l risk sexual abuse closure children home abandonment mother drunk disclosure hand occurred adolescent maximum temporary physical security disclosure prompted adolescent demand security demand met l allowed two choices denying secret continuing act maintain added security case partial disclosure successively people powerful socially closer relation mother first adolescents unit junior nurse junior doctor senior staff convinced able inform social worker mother pattern adolescent crisis characterised ambivalent adolescent adults appear behave ambivalently appear know secret time times appear reluctant know secret l described ambivalent relationship secret i abused avoidant pattern figure 2 avoidant pattern crises starts declaration crisis adults adults closest adolescent appear concerned danger adolescent compared peripherally engaged adults adolescent denies distress perturbed behaviour appears adults crisis precipitated adolescent states request crisis continues request ignored rejected accepted increasingly distressed adolescent states adult taken request seriously alternatively taken seriously acted crisis escalates second stage reached security offered adolescent adolescent readily immediately confides secret securing 589 secrets security crisis adults adults know secrets b security adolescent adolescent tells secret d status quo c secret disappears devalued adults security withdrawn figure 2 avoidant pattern adult adults response know secret devaluing seriousness secret adolescent adolescent insists importance secret physical security offered adults withdrawn third stage secret disappears discussed pattern called avoidant adults adolescent avoid discussion called secret crisis adults adolescent avoid devalue information crisis case 2 m 15 year old girl history repeated episodes cutting overdosing admission adolescent unit prompted anxieties teacher middle aged lady written scores love letters m abandoned 18 months placed adoption three occasions returned children home longest stay resident prior admission unit m traced written letter biological mother mother respond m recently lost psychotherapist 5 years duration four fellow residents children home successfully adopted brother broken contact m proposed contacting mother admission cutting overdosing recurred m requested return children home asked stay adolescent unit recurred requested fostered last request granted staff unit responded crisis increasing surveillance security m passively accepted increased confinement surveillance times m stated secret staff know mother last recognise m daughter m death door m die time staff response say implying saying knew guessed m wanted re disclosure secret m behaviour settle staff surveillance relaxed secret forgotten times crisis staff referred m longing mother mwas impassive saying mother relevant secret m desire gain mother love remained unacknowledged outside crises m staff knew secret times crisis security granted m revealed secret disclosed worthless m adults believing true crisis secret valuable m secret valuable m long kept told adults secret m feared secret seen fantasy requests realised relationship mother changed secrecy gave value information turn protected adolescent 590 d goldberg secret adults distressed adolescent chaotic b adolescent searches secret protection provided adolescent chaotic d status quo c adolescent gives search secret security removed figure 3 chaotic pattern chaotic pattern figure 3 onset chaotic pattern adults adolescent demand adolescent secured chaotic crazy adolescent give coherent information appears unable protect security provided adolescent sane i e coherent giving information capable providing security second stage adolescent searches lost secret demanding know secret security withdrawn adolescent continues searching convinced security fully withdrawn adolescent stops searching lost secret stops mourning loss situation reverts status quo term chaotic refers adolescent relationship secret e g looking place case 3 d aged 16 admitted unit mute incontinent times catatonic recovery perplexed asking quizzical vaguely paranoid questions rarely answered questions frequently stopped talking midsentence look enquiringly investigating extraneous sounds look disappointed found sounds refer d admitted care local authority siblings age 5 fostered intermittently 10 years difficulties foster mother search biological mother allow home request daughter taken back couple days meeting recovery mother described like daughter live described idyllic scene practical details enquired mother realised difficulties daughter home day two staff member pressed issue d live mother discharge mother stated able cope longer weekend time d distracted interview time discussion live mother sat edge chair intently watching mother facial expressions mother stated d come live d immobile arms fixed extended position catatonic 3 weeks d episodes anxiety march unit investigating noise appearing search stopped staff enquire mother going live mother discharge episodes lasting hour occurred times mother failed turn pre arranged visits d 591 secrets security crisis adults secret stated hinted adults b secret denied adolescent security increased d status quo c secret forgotton staff disagreement conditions confinement figure 4 rigid pattern expecting news social worker searching episode d miserable sequence security information disclosure episodes seen detail family meeting outlined girl acted crazy escorted family meeting searched secret coherent mother appeared giving straight forward answer mother retracted earlier promises d catatonic silent meeting d stopped asking questions reassured staff alright couple hours silence d returned prior state acting crazy secret belong adolescent held mother security offered m searched secret stop security withdrawn case adolescent looking secret adults examples rigid pattern figure 4 adults responsible adolescent call crisis negotiations admission parents legal substitutes hints states secret adolescent present adolescent admitted adults provide security adolescent responds increasing resistance confinement control second stage adolescent denies secret spends time resisting rules security unit third stage unit staff longer talk secret securing adolescent takes priority followed return status quo crisis called secret re stated pattern called rigid adolescent states secret exist case 4 r aged 14 dieted danger dying despite protestations contrary admission discussions r parents unit staff mother extreme thinness commented i ve weight replied break negotiations father privately informed staff member wife undergone operation malignancy 2 years suspected r knew wife r know mother operation discussed family r shouted loudly mother description heard repeatedly screamed ill r admitted gained weight staff ensured security confinement insisting remained bed rest ate meals exercise induce vomiting r spent 592 d goldberg time arguing rules confinement asked family situation anorexia reply i don t know i t think time confinement possible discuss secret r family meetings regaining weight liberated restrictions lose weight prompting crisis staff onset new crisis succession secrets revealed parents different members staff senior duty secrets mother disturbed early life teenage anorexia father redundancy anxieties future crises called prompted weight loss disclosure followed restrictions re imposed secrets denied adolescent weight re gained disclosure safety alternated secrets stated crisis crisis secrets denied talked times crisis adolescent refused talk problems led admission adolescent criticised rules institution particular rules designed adults ensure safety life rules security provided staff problem problem promoting crises discussion secrets maintain generate patterns relationships crisis pattern person thought holding secret person wanting know different ambivalent avoidant patterns adolescent thought secret parents staff thought demanding chaotic pattern unknown adult thought secret adolescent demanding rigid pattern parents demanded adolescent keep knowledge secret information secret holder indicates secret person believe secret value secrets enable holding secret power wanting know secret secret revealed holder looses power relation demanding secret value secret maintained kept secret examples ambivalent avoidant patterns denial silence secret made secret valuable disclosure person secret values social relationship strengthened ambivalent pattern avoidant pattern secret diminished relationship weakened disclosure information interacted surveillance confinement ambivalent avoidant patterns securing adolescent prompted disclosure secrets ambivalent pattern staff member refused keep secret adolescent demanded security chaotic pattern confinement adolescent allowed adolescent search secret rigid pattern confinement allowed knowledge secret secret secrets seen representations relationships secret description important aspect adolescent relationship parents main care giver first l secret parental sexual abuse desire rescue mother alcohol like examples secret contained description current relationship hoped future relationship case end parental abuse maternal alcoholism second secret m 593 secrets security rescued mother secret described m current estrangement mother wish repair magically similarly chaotic pattern desire secret suggested share important secret mother wished rigid pattern secret mother cancer expressed family concerns possible early death mother desire die content secret description current social relationships wish different ones crisis seen repeated attempt change current social relationship entombed secret hoped adolescent exhorted talk imparting information relationships admission adolescent psychiatric unit seen rite passage adulthood declarations adolescent social relationships seen marker change promoter change relationships declaration adolescent social relationships entombed secret create change social category adolescent clearest provided second m declared secret belief mother rescue step adulthood public forum declaration made greater staff felt m made step adulthood naming longing seen step accepting unlikelihood realisation long m kept secret maintained child adult relationship mother discussing secret step saying occur crisis process revelation surveillance containment adolescent knowledge social relationship public act making public causes secret loose power social relationships far avidly protected change case 1 ambivalent pattern secret presumed sexual abuse description important aspect adolescent relationship parents fact adolescent kept information secret maintained relationship parents described secret secretiveness secret constitutes social relationship surveillance relationships public recognition form social process change relationship terms adolescent unit ensured adolescents possessed secrets gave institution progress adulthood granted adolescent constructed made public institution secret earlier social relationships crises social process moves adolescent adulthood series interactions beliefs actions participants outside institution secrets disclosed searched constrain interactions adolescent carers secret represents relationship four patterns crises described parallel attachment behaviour seen infants prime care giver returns period absence strange situation ainsworth et al 1978 main solomon 1991 names four crisis patterns chosen highlight parallel attachment behaviour infancy place secrets adolescent crisis secrets mediated attachment behaviour representation behaviour cf internal working models crittenden 1990 individual crises particular adolescent psychiatrist unit understood attachment framework placed wide context national local institutional family personal interactions resources beliefs 594 d goldberg acknowledgements thanks go young people members staff unit help interest discussing subject paper dinah eastop john coleman two anonymous reviewers helpful advice encouragement references ainsworth m blehar m c waters e wall 1978 patterns attachment new jersey lawrence erlbaum bloor m mckeganey n fonkert d 1984 foot eden sociological study range therapeutic community practice london routledge blumer m 1979 concepts analysis qualitative data sociological review 27 651 677 crittenden p m 1990 internal representations attachment relationships infant mental health journal 11 259 278 edgar i 1990 social process adolescence therapeutic community anthropology riddle sphinx spencer p ed aso monograph 25 london tavistock frankenberg r 1991 time health 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