I recently spent some time in Australia and contributed to three child care conferences with a particular focus on residential care. It was striking to discover that many agencies wanted to explore what constituted ‘therapeutic’ residential care.
This was a particular focus for the people in Victoria State (which includes Melbourne). There the Government has provided funds for the development of training for residential workers who, in the main, are not highly qualified in child care subjects.
This is interesting because it is also a something that we in the Scottish Institute for Residential child Care (SIRCC) are asked about quite regularly and also something that two of my colleagues have written about in a chapter in a new book on residential care.*
In this column I want to think a bit about what is meant by this phrase and to ask why it is seemingly in demand. I’ll come onto definitions in a moment, but I think it is worth thinking about why people are interested in something therapeutic.
Interest in therapeutic care
One good reason is that increased interest does seem to be related to the needs of children. There seem to be some children and young people, (including some quite young children) who are not being helped by our traditional services – in the majority of cases in the UK this means foster-carers. Certainly in SIRCC we regularly get asked if we know whether there are any ‘therapeutic residential services’ for young children who can’t seem to settle in foster-care and who have exhausted the skills and capacity of even experienced foster-parents.
In these circumstances it seems that social workers recognise that they will need a residential placement of some kind. Given the child’s great emotional, behavioural or relational difficulties, they find themselves looking for something ‘therapeutic’, even if they don’t always have a clear view of exactly what it is they want, other than a placement that can ‘contain’ some very difficult behaviour.
I agree with the comment from the Waterhouse report quoted by Irene (Stevens) and Judy (Furnivall) in their chapter, “All residential placements should be designed to be developmental and therapeutic rather than merely custodial” (2000, p.856). In their chapter, Irene and Judy describe a number of different types of therapeutic residential care which they categorise as ‘holistic therapeutic approaches; therapeutic communities’ or ‘discrete therapeutic approaches’. The latter includes two streams; those influenced by the mainly North American ‘milieu therapy’ or lifespace work and cognitive behavioural programmes.
In England there have been a number of long-lasting therapeutic communities such as the Caldecott community. However, in Scotland we have had very few of such establishments and their style of work is not well known to residential practitioners. What we do have in Scotland, though, are a few places which explicitly claim to be using a ‘therapeutic milieu’ approach.
In these sorts of settings the managers have adopted an understanding that the whole, day-to-day life of a residential group, young people and staff together, can create a supportive and caring environment which can meet the needs of very vulnerable children. In these places there is an understanding that doing ordinary day-to-day activities in a thoughtful and reflective way can help children develop a different and more positive self-concept and regain trust in adults that will prepare them better for the future. A belief in the possibilities and value of ordinary activities can also lead to situations when children open up and share some of their deepest worries and hopes.
This type of work is given a theoretical framework by Adrian Ward in his concept of ‘opportunity-led work’, which is something that features in the training courses run by SIRCC. It is very noticeable how frequently residential workers mention an occasion when they were driving in a car with a young person as a time when they made a deeper connection and the young person was able to talk about something important but difficult.
This tells us something about the vital ‘side-by-side’ nature of the work, rather than ‘face-to-face’ eye-contact type of encounter, which can be valuable but is rarely initiated by a young person. The other classic residential scenario when this type of conversation is often reported is when staff and children are washing dishes together. I am convinced that residential homes that have a good ethos and where staff understand the value of such encounters are therapeutic in a broad sense.
The implications of terminology
This leads us to an interesting issue: the language of therapy or treatment and why the word ‘therapeutic’ is coming back into more common use while the word therapy is not so prominent. In child care social work generally for the last quarter century or more there has been a trend away from, or perhaps a lack of confidence in, ‘treatment’ methods and approaches. ‘Care-planning’ (a functional approach without any theoretical orientation) has become the framework in which all the ‘needs’ of a child are to be addressed. Occasionally it will be felt that a child needs some specialist help with a very serious problem which social workers and carers are not coping with, but usually this is addressed by referring to the Child and Adolescent Mental Health Services.
The real needs
Yet the multiple placement breakdowns – i.e. those children not responding to a standard ‘care-planning’ approach - are driving more and more social workers to see that what their child needs is a placement which has got some of this ‘treatment’ built in and that is what they mean when they say they want something that is therapeutic. This was also the case in Victoria in Australia – there the need is for specialist residential homes for teenagers who are proving very difficult to care for in any other setting. There the government department responsible for child care social work has funded the agency Berry Street Victoria to run a unit which has been set up with a therapeutic intent.
It is still early days but it will be interesting to see what they feel the lessons are from that place. For make no mistake, there is a crying need for care which has a therapeutic intent. The trend had been for normalisation and for caring for as many children as possible within families or small homely residential units. There is much that is admirable about this trend but we must not deceive ourselves that all the country’s most vulnerable and hurting children can be cared for simply by normal upbringing in small scale environments with untrained (or poorly trained) carers.
If you doubt this, then I ask you to consider why there has been an explosion of singleton so-called ‘residential’ units across the UK, or why there are so many children in secure care in Scotland. Some of our children need homes where they can get ‘treatment’, ‘help’, ‘close support’, ‘therapy’ - call it what you will. Some may be helped by individual treatment or counselling or cognitive behavioural therapy programmes on anger management and so on.
Providing therapeutic care
But there are others who will benefit from residential group care, provided for either in residential homes or foster-homes. The carers in these homes need to know something about how to meet the needs of ‘wounded’ or difficult children and have the resources to understand and respond to challenging behaviour in ways which are ‘developmental and therapeutic’, to quote Sir Robert again.
There is no need to try to find one ‘best’ form of therapeutic practice, given the breadth of meaning of that word and the range of needs that children and young people have. But in any particular residential unit the managers need to be clear about what they mean by ‘therapeutic’ so that all the team have a shared understanding and set of reference points for their work.
One starting point is to have a written down philosophy for each home which encompasses the values and approaches used in the unit. If we are clear about what the philosophy of our unit is and if we can become more specific about what approaches or methods of practice we use, then we can begin to deliver care which addresses both children’s developmental needs and their need for reparative, or therapeutic, care.
Stevens, I & Furnivall, J. (2007). Therapeutic approaches in residential child care. In A. Kendrick (Ed.), Residential Child Care: Prospects and Challenges (Research Highlights in Social Work Series): Prospects and Challenges (Research Highlights in Social Work Series). London: Jessica Kingsley Publishers. Research Highlights in Social Work 47.