“In Australia, the most
clearly articulated model of Therapeutic Residential Care is that offered by
the Lighthouse Foundation (Ainsworth 2012; Barton, Gonzales and Tomlinson 2012)
that owes much to the Cotswold Community in the UK.” (McNamara, 2015)
Introduction
In recent decades therapeutic models for children and young
people, who have suffered trauma and who are in residential or foster care have
become more widespread. Working with
organizations to develop therapeutic models is one of the main areas of my work.
I have done this work for over 20 years in various countries such as UK,
Australia, Ireland and Portugal.
This group of young people have major difficulties, which can
cause serious if not disastrous lifelong problems for themselves, others and society.
Specialist intervention is needed, and it is often expensive. Therefore, many
governments and professionals have been focused on discovering ‘what works’. This article, which is much longer than
anything I have posted before, attempts to explain what a therapeutic model is
and why it is so important.
As McNamara’s quote above implies, there are universal elements in
therapeutic work with people who have suffered trauma and adversity. The core
principles of a therapeutic model tend to be transferable from one setting to
another. These are principles such as the centrality of relationships, a phased
approach beginning with safety, the need to regulate emotion and the importance
of the whole system. The value of
having a coherent model is in itself a core principle. The principles are informed by research and
the best evidence available. However, exactly how these principles are
implemented in practice needs to reflect the local culture. There will also be
some aspects of a model that are unique to a specific culture. Models must be culturally sensitive. They must be grounded in cultural values, language
and belief systems.
This article is specifically relevant to work with children and
young people who are in residential care or foster care, throughout the world.
However, much of it may also be relevant to other areas of therapeutic work. A therapeutic model is in effect a method of
working with human suffering, with the aim of achieving improvements. Though the language is new, the idea is
not. In work with children and young
people models have certainly existed throughout the 20th century.
They tended to be created by pioneers, who implemented and passed them on. This was often done by creating a
centre/institution/therapeutic community which embodied the model. Sometimes, even when excellent outcomes
seemed to be achieved, people outside of these centres understood little about
the practice. There was sometimes an air of mysticism. Although, pioneers such as Bruno Bettleheim in the USA, Barbara Dockar-Drysdale in
England and John Brown in Canada among others, they did write substantially about their work, ideas and methods.
One of the main differences these
days is a growing expectation for a model to be clearly articulated in a
written document. This makes it potentially
more accessible. It also means that it can be more easily critiqued and
challenged. Following on from that there
is an expectation that a model should be informed by research and evidence.
However, there are also potential
problems with a written model. The interpretation of it may not be
consistent. It may also appear to be like
a manual that will provide all the answers. This is always an issue in human
services, which tend to involve ‘messiness’, unpredictability and pain. There can be an understandable wish for order
that a ‘manual’ might appear to provide. As Thompson (2000, p.80) argues,
If
we expect theory to provide ready-made answers to the questions practice poses,
we are misunderstanding not only the nature of theory, but also of
practice. Theory cannot provide simple
answers which tell us ‘how to do’ practice.
Theory can only guide and inform.
Theory, practice and the relationship between them are all far too
complex for there to be a clear, simple and unambiguous path for practitioners
to follow. Theory provides us with the
cloth from which to tailor our garment, it does not provide ‘off-the-peg’
solutions to practice problems.
Recovery is a process rather than an event and there is no perfect recovery. Thompson (2000) also talks about the ‘notion of uncertainty, of no security and no guarantees’ as being important for practice. There is
not a simple solution to recovery from trauma.
It cannot be prescribed but needs an environment where it is safe to
think about the trauma, experience feelings about it and make reliable
provision to heal it. This type of
environment has been referred to as a ’holding
environment’. Whilst having our guiding
principles and experience we must also keep in mind that every child, worker, situation organization and cultural context is
unique.
So, if we are going to have clearly articulated models, we need to
use them in the right spirit. Not as rigid doctrines, but something with
helpful parameters, which provides guidance and supports people in their
difficult work. To assist with, rather than replace thinking. This article attempts to provide an explanation
of what a therapeutic model is and why it is important to have one.
I deliberately use many references in this article, partly to show
the depth and consistency of thinking that has emerged across the world. During the last 20 years or so, there has
been significant international research into what works in enabling the best
outcomes for children (and young people) who are in the ‘Looked After’ or ‘Out
of Home’ care system. While it is often
said that that we have little ‘evidence’ of what works, it cannot be denied
that we do have a vast amount of experience and research to inform us. I think it is important to acknowledge the
great value of this.
International
Research and Development
This article is based on my own experience and the vast research
and experience of authors from USA, UK, Australia, New Zealand, Ireland and
Canada. The research has examined all
past studies and has reached a consistent point of view on the fundamental
principles of positive service provision.
During the same period there have been major advances in the
neuro-scientific research on child development, the impact of trauma and the
most effective interventions to facilitate recovery. However, as McHugh and Meenan (2013, p.251) argue,
doing this well is a complex challenge,
The
needs and problems of many children in care are complex and difficult to serve
appropriately. Or more correctly, their needs are deceptively simple, but
delivering the right response is deceptively complex (Gilligan, 2001: 1).
Taylor (2012, P.100) highlights the significant work of Clough et
al. (2006) who,
…found that a significant factor in successful residential
care is a coherent model based on a clear theoretical perspective.
and (ibid, p.3) referring to
Fonagy (2006) that,
Traumatized children benefit from the experience of
living in a carefully considered, well-structured and coherent psychosocial
environment where interpersonal interactions are thought about and reflected
on.
Numerous effective therapeutic
models have been created during the last two decades. Based on their research
into the implementation of different models of care, Macdonald and Millen (2012) recommend,
The
introduction of an explicit model of care, championed by the heads of homes and
delivered in collaboration with a whole staff team, has much to recommend it in
terms of the existing evidence regarding how best to improve the quality of
care.
Most importantly a therapeutic model helps improve staffs
understanding of children and their needs, so that better outcomes can be
achieved.
Understanding
how children’s
responses may have been shaped by maltreatment, including neglect, is thought
to help staff respond sensitively and appropriately to challenging or unhelpful
behaviour, and to provide opportunities for new, positive experiences that may
help to reverse the adverse consequences of early childhood adversity
(Cicchetti and Rogosch, 2001; Moses and Barlow, 2006; Gunnar and Quevedo,
2007). (Macdonald and Millen, 2012).
What
is a model?
While most people might not
think consciously in terms of models - in essence, it is like John Bowlby’s (1969)
concept of internal working models.
Bowlby used the term in his work on attachment theory. It may be one of the first uses of the word
model in our field of work. It is the way we make sense of the world, our part
in it and our purpose. For instance, what does one want to achieve; what
methods will we use; what evidence exists about the effectiveness of the
methods; and what are the potential outcomes; including unintended outcomes or
side-effects? (Tomlinson, 2014). Macdonald and Millen (2012) put this
into the organizational context,
At its
core, a theory of change spells out how the core components of an intervention
(its ‘inputs’) bring about changes in staff behaviour and organisational
processes or culture (the ‘outputs’) and why
or how these changes are thought to benefit children and young people (‘outcomes’).
They continue to elaborate how change
takes place,
The
implicit theory of change appears to be as follows: by bringing staff to a
shared understanding of trauma and its effects, and providing them with a
language with which to communicate that understanding, staff can bring about
the changes in organisational behaviours, structures and processes needed to
address the detrimental effects of trauma.
As Mackay
(2014, p.37) states it is vital that the model is adapted to the specific needs
of the children involved,
It is
important that whatever model is developed it is made to fit the child and not
the other way round.
Redshaw (2001, p.16) who
has carried out extensive work on model development outlines the following
qualities of a model of care.
·
It as a
well-defined set of procedures and practices
·
It is proactive,
not reactive
·
Increases
consistency
·
Aids in data
collection, evaluation and reviews of program
A model can provide guiding principles, standards, specific
techniques, some do’s and don’ts. But most importantly it should equip the
people doing the work with the ability to think within a framework and work
things out together. A model provides
parameters within which things can be tried and monitored. What works can carry
on and what doesn’t may need re-thinking or persevering with. Having a
benchmark provides a point from which new ideas can be critiqued. If there
isn't a benchmark how do we notice how far something is drifting - a bit like
walking in the fog, without even a vague marker to keep a sense of direction.
Aims of a model
The aim of a model is multi-fold:
1. To provide knowledge and understanding so
that the children’s needs will be responded to in the most effective
manner. This requires the creation of an
ethos, which will influence every aspect of the children’s daily life.
2. To provide a consistent and congruent
approach in the best interests of the child (Anglin, 2002).
3. To provide guidance on specific therapeutic
interventions, which target specific needs identified through assessment.
Wall et al. (2013, p10) referring to Redshaw (2011, 2012) claim,
The
intention of the model is to provide a body of knowledge and a practice
framework to assist in the avoidance of the age old challenge to residential
care practice which sees workers fall back on their own personal parenting
practices and belief systems and instinctive reactions to young people which
are often not helpful; the model seeks to support workers to view the young
person from multiple perspectives to allow a holistic approach to intervention
and healing.
Evidence-based practice
The
emergence of therapeutic models has been influenced by the development of
evidence-based practice. As Farrelly (2013, p.123) explains,
Evidence-based
practice has become a byword for better, more appropriate and efficient
practice. In essence, an evidence-based approach asks that practitioners use
the best available evidence to guide and inform their practice. There is
nothing particularly new about the idea that policy and practice should be
informed by the best available evidence/Evidence-based practice (EBP) was first
introduced in medicine and allied health professions. More recently it has been
advocated in social work as an alternative to 'authority-based practice' or
practice based solely on the expertise and experience of practitioners (Edmond
et al., 2006) …EBP represents a move away from opinion, past practice and
precedent and towards a decision-making framework that relies on greater use of
research and evidence.
Evidence
from practice becomes part of the knowledge that underpins social care. Knowledge = evidence + practice wisdom +
service user and carer experiences and wishes.
All three elements are equal in contributing to knowledge. Therefore researchers, practitioners and
service users all have an equally valid role in contributing to knowledge
(Farrelly, 2013, p.131). A model will
influence practice and practice will influence the model. This leads to the concept of the
‘research-minded practitioner’ (ibid, p.132).
In
my early twenties, I began work at the Cotswold Community, a renowned
therapeutic community in England. The
development of its model, though the term was not used then, had involved leading
experts in the field. We had student
placements and visitors from all over the world. I had virtually no relevant work
experience.
However, I was struck from the
beginning by how we were encouraged to reflect upon our experiences and make
contributions that might further develop the model. We adopted the same approach in the way we tried
to listen to and learn from the children.
Connected with this philosophy, McHugh and Meenan (2013, p.258) argue
that the challenge is ‘to move from learning about to learning with children in care’.
Farrelly (p.124) adds a cautionary note,
While
the arguments for the adoption of an evidence-based approach may he convincing,
it should he noted that finding and using research, particularly of high
relevance and good quality, is not always easy.
It is very difficult to have what would usually be called
scientific evidence, in such a complex field of work with so many variables.
Research-Informed
As said earlier, it is vital that a therapeutic model is informed
by research and the best knowledge available. Referring to social care
guidelines in Ireland, Farrelly (2013, p.123) states the importance of practice being
informed by research,
The
Department of Health and Children's (DoHC) policy document Working for Children
and Families: Exploring Good Practice outlines seven management principles that
should underpin child and family services, including the need for practitioners
and their managers to 'ensure that their practice and its supervision are
grounded in the most up-to-date knowledge' (2004: 15). More recently, the
Health Information and Quality Authority's (HIQA) National Standards for the
Protection and Welfare of Children state that standards need to be
person-centred and 'based on evidence and best international practice’ (2012:
iii).
Farrelly
(2013, p.133-4) argues that the amount of the ‘research that
constitutes 'quality evidence' remains debatable’ and warns of adopting a
too dogmatic approach to evidence-based practice,
Social
services are by their very nature fluid and dynamic, and practitioners need to
be mindful of the potential to adopt a dogmatic approach. Sheppard (2004: 23)
argues that practitioners should be 'looking at information that can help
provide guidance and better informed
judgements but not certainty'. Perhaps, given the nature of the debate and
the nature of the work that the social professions are engaged in, the term
'research-informed practice' might be more applicable than 'evidence - based
practice'.
Institute
of Child Protection Studies (2006, p.12) in Australia refer to the research of
the last 20 years and particularly that of Clough et al. (2006). They
highlight some of the universal principles of a model,
Whilst the
literature review has not identified a specific model that is easily replicated
it has identified the important elements for providing such care. These elements include:
·
the creation of a clear ethos and positive culture
·
individualised assessment and planning
·
collaborative practices
·
the involvement of family members
·
the involvement of young people in planning and decision making
·
positive peer relationships
·
a coherent theoretical framework with the identification of values,
objectives of the programme, theories of behaviour, of intervention and of
organisation
·
developing resilience through education, learning and leisure
interests
In particular,
the maximising of the day to day and opportunity led communication and
connection to promote healing relationships seems to lie at the heart of
effective residential care.
Brandt (2014, p.11) states the importance of a
therapeutic research-informed model,
Ideally, therapeutic work is derived from and grounded in theoretical constructs,
research evidence, and the logical construction of strategies or approaches
where work is improvisational and contextual—and optimally this process is
guided by an explicit therapeutic model.
Kezelman and Stavropoulos (2012, p.xxviii) in their work on
creating trauma informed services affirm the necessity of research.
Research
shows that the impacts of even severe early trauma can be resolved, and its
negative intergenerational effects can be intercepted. People can and do
recover and their children can do well. For this to occur, mental health
and human service delivery need to reflect the current research
insights.
Key elements of a model
Irrespective of which theories inform
residential care practice, it has been argued that effective residential care
needs to incorporate:
(a) a
clearly thought-out philosophy of treatment or care (Clough, 2008; Hillan,
2006, Sinclair and Gibbs, 1998);
(b)
child-centred practice, in which service provision is matched and responsive to
the child’s need, rather than the child’s needs being subordinate to the
service model (Clough, 2008; Hillan, 2006);
(c) a
service-wide commitment to staff support and continuous learning (Hillan,
2006).
McLean
et al. (2011, p.11).
Institute
of Child Protection Studies (2006, p.31) in Australia state,
James Anglin
(1999, p.144) has written about the distinctive nature of what he calls the
‘child and youth care profession’ which he says has five characteristics:
• a focus on the growth and development of
children and youth
• concern with totality of a young person’s
functioning, rather than one part of functioning
• ‘a social competence perspective’, which builds
on strengths, rather than a problem-based approach
• direct day-to-day work with children and young
people in their environment, rather than being restricted to interviews or
sessions
• the development of therapeutic relationship with
children, their families and other helpers.
Whole
system approach
Clough
et al. (2006) found through their research into what works in residential care
that positive outcomes for children, are linked to a strong children culture,
which in turn is linked to a strong staff culture. This finding is supported by
Warner (1992) who found that positive outcomes were only correlated with
leadership with leadership and clarity of purpose. Therefore, it is important that
a therapeutic model considers the whole system and not just the direct work
with children.
A whole system model is one that
spans across all aspects of the child’s daily living situation. It requires that the relationships between
the different parts involved are fully integrated into the model. Childhood trauma takes place in an
environment - trauma is in the system not the event. Cissy White (2018) explains this very well,
Being raised with ACEs (adverse childhood experiences) is an environment, not a
series of incidents that happened here and there. I lived every day with
scarcity and lack. Trauma was baked into my being, as were my responses.
Similarly,
therapeutic work also takes place in an environment with a network of
relationships. As Macdonald
and Millen (2012) state,
Models articulate the inter-relationships of their
component parts and the pathways of change embedded within them.
Kezelman and
Stavropoulos (2012, p.xxx) make
the link between the organisational context and the recovery process,
Research now shows that resolution of trauma
equates with neural integration. It also shows that longstanding trauma can be
resolved, and its negative intergenerational effects intercepted. But for this
to occur, mental health and human service delivery (i.e. as well as direct
treatments) need to reflect the current research insights. Experience is now
known to impact brain structure and functioning, and in the
relational context of healing this includes experience of services.
Neural integration is not assisted – indeed is actively impeded – by
unintegrated human services which are not only compartmentalised, but which
lack basic trauma awareness.
They
(p.16) emphasize the importance of the ‘whole system’ approach,
Both
administrative and clinical experience suggests that attributes of the system
`as a whole’ have a very significant impact on the implementation and
potentially the effectiveness of any services offered.
Whole system models focus on
providing training to all staff within the organisation, whatever their role. In one organization I worked with
trauma-informed training was given to the whole workforce. This included, care
workers, manager’s, therapists, admin staff, human resources, finance and
maintenance. The effect of this
training, which everyone did together contributed to a cultural
transformation. Not only did the
training enable staff to be better trauma-informed, but the way it was done was
inclusive, brought people together, helped to build connections, and gave
everyone a shared understanding of the organization’s primary task.
Importance of a theoretical
base
UK’s Social Care Institute of
Excellence (2012) in their research into different models, highlight the
helpfulness of having a theoretical base,
Staff who can think clearly and logically about
their work use a set of strategies to understand children’s behaviour and
critically evaluate their own actions and those of others and use their
understanding to act in the best interests of children are likely to be better
at their job than those who have no framework.
There is a long tradition of specialized
therapeutic services for children having a strong theoretical base. Fahlberg
(1990, 51) emphasized the importance of a theoretical base to residential
treatment,
The most
important task of treatment must be clearly and succinctly stated. Specific
problems and dynamics vary from child to child, but a philosophy of treatment
must clearly identify the category of problems that are most essential for the
programme to confront if successful treatment is to occur.
In
more recent times, the field of neuroscience has become a central part of the
theory as Perry
(2014, p.30) explains,
A developmentally sensitive and
neurobiology-informed clinical approach can aid the clinical team in
understanding the impact of maltreatment and other developmental insults.
Stien
and Kendall (2004, p.7) claim that the new neurobiology represents a confluence of two strands of brain research – attachment theory and
childhood trauma,
Whereas traumatologists focus on abnormal development,
attachment researchers often examine the brain under conditions of normal
or optimal development. Thus, when taken together, these two strands of
research clarify the key mechanisms behind both mental health and
psychopathology in children. Whereas secure attachment produces a
growth-facilitating environment that builds neuronal connections and
integrates brain systems, strengthening the capacity to cope with stress; abuse
and neglect induces chaotic biochemical changes that interfere in the
maturation of the brain's coping systems, leading to problems with emotional
regulation, relationships, and identity formation (Schore, 2001).
Historically
John Bowlby and Donald Winnicott had a huge influence on the development of
therapeutic approaches, as outlined by Byrne (2013, p.143),
Possibly
the most influential psychodynamic theorists within therapeutic social care are
Donald Winnicott and John Bowlby. Winnicott's work with therapeutic communities
in Britain is the primary influence for contemporary theorists in this area
such as Adrian Ward (Ward et al., 2003). There probably is no social care
practitioner in Ireland whose practice has not been influenced by John Bowlby's
attachment theory (see, for example, Fahlberg, 1994).
The leading neuroscientist Bessel
van der Kolk (2014) referring to attunement which is a vital concept in
neuroscience claims that,
Donald Winnicott is the
father of modern studies of attunement.
Macdonald and Millen (2012) argue that a
theoretical base can help a service to be effective,
The importance of theory informed therapeutic care
and the centrality of relationship- based social work were also found to be
essential in promoting resilience within the young people.
Fosha
(2003, p.276) claims that the challenge is to operationalise the substantial
evidence base of affective neuroscience into a `neurobiology of healing’.
Macdonald and
Millen (2012) in their review of different models say that,
Each provides a framework whose constituent
theories are intended to help staff to understand:
·
How trauma impacts on children and young people.
·
How and why their ways of coping might be maladaptive.
·
How and why agencies and staff respond in ways that are not always
helpful.
· How they might
change. Each emphasises the importance of helping staff develop the knowledge
and skills necessary to help those they care for.
Without a theoretical base, it is difficult for
staff to be trained to a level that enables them to provide consistent,
coherent and appropriate care.
Different
theoretical perspectives
Mackay (2014, p.22) explains the need for
approaches informed by different perspectives,
The growing body of knowledge in the areas of
attachment, trauma and neurodevelopment tells us that it takes multiple
therapeutic interventions on a daily basis to effect permanent and lasting
change for these young people. These interventions
are most effective when carried out by people with whom the young person has a
relationship (Boyd, et al., 2013; Burnside 2012; Child Protection Development
Department of Communities 2011; Cook et al., 2005; McClung 2007; Perry 2009;
Prasad 2011; Van der Kolk 2005).
Kezelman and Stavropoulos (2012, p.76) also argue the benefit
of drawing knowledge from different theoretical perspectives,
While effective treatment of complex
trauma needs to address several key dimensions (i.e. irrespective of the
particular approach used) the current literature also advises of the need for knowledge of more than one modality.
Many theories may be useful for different
aspects of the therapeutic task.
Theoretical knowledge from the following fields are essential in all
therapeutic residential services for children,
- Child Development
- Attachment
- Neuroscience
- Trauma
- Loss and Grief
- Psychodynamic
- Systems
Training
Only
when there is coherent model is it possible to design appropriately focused
training. The Department of Communities (2010, p.13) highlight the importance
of staff training,
International research also
speaks to the need for well-trained staff and notes that one of the most
negative factors influencing poor outcomes for young people is untrained staff.
According to expert Jim Anglin, it is ‘a disturbing fact that those who have
the most complex and demanding role in the care and treatment of traumatised
children have the least, and in many cases, no specific training for the work’ (Anglin
2002b, p113). Acknowledgement of the
need for enhanced training for residential staff is increasing both nationally
and internationally.
McHugh and Meenan (2013, p.250) make a similar point,
Professional
training provides opportunities to develop and practise skills and heighten
self-awareness. These opportunities, coupled with relevant theory, promote a
reflective approach to social care practice. It is the responsibility of the
individual practitioner and of the service provider to ensure that all staff
are both aware of and equipped for their professional role.
Furnivall et al. (2012,
p.49) state,
For all practitioners, however, it is
crucial that training is delivered by people who understand the context in
which their practice takes place and in a manner which is congruent with an
attachment-informed approach.
The emphasis of training needs to be on
improving everyone’s understanding of the children, how their development has
been impacted by trauma and what approaches are most likely to help. In her paper, The Importance of Child Care
Training, Barbara Kahan (1995, p.1) argues that we would expect lawyers,
dentists, doctors and teachers to be trained, qualified and up-to-date with
recent knowledge,
…so why are we prepared to tolerate a situation in
which, by definition, some of the most needy and traumatized children in our
community are cared for by people who, however well-intentioned, are neither
trained, qualified nor, in many instances, knowledgeable about their needs and
how best to deal with them?
Having a
model is the most important thing
Whilst many
different models have been created the underlying principles tend to be very
similar. The research is consistent on the importance of key matters, such as
the importance of relationships, attachment and attunement, meeting emotional
needs, consistency of team work, a whole system approach, etc. It can be argued
that as long as a model is based within these key parameters, it is the
coherency and consistency that it brings that is most important. Macdonald and Millen (2012) state,
There may be merit in the argument that it is providing staff with “a
framework‟ within
which to think about their work that matters, rather than a particular
framework. Staff who can think analytically about their work, who can better
understand children’s behaviour and critically appraise their own actions and
those of others, and who can draw on their understanding to act in the best
interests of children, are likely to be better at their job than those who have
no such framework. They are also likely to have more job satisfaction and,
particularly when whole staff teams are trained in that framework, more likely
to behave consistently – something we know children value.
Janet Rich, (2009) strongly supports this view,
It
is almost certainly the case that the specific model of care adopted is far
less important than the fact of there being a model of care that is underpinned
by an empirical and theoretical evidence base, that the staff and young people
are signed up to, and that is supported by both an established culture within
the home, by sound leadership and supervision structures and by appropriate
training and resources.
Like parenting, what helps children
develop, is as much to do with the quality of relationship between the carers,
and the nurturing and predictable environment provided – rather than the exact
detail of the approach and personality type of the carer. It is helpful if they
have similar models of what children need. Byrne (2013, p.146) agrees with the
view that a coherent model improves consistency of practice,
When practitioners identify themselves as providing therapeutic
care it is important that they are clear about the approach that informs their
practice. The reason is that where several practitioners are working with the
same client, the active interventions will be different depending on the theory
influencing each individual practitioner. Mixed approaches could lead to
inconsistency in service provision and unhelpful or confusing outcomes for the
client.
McLean et al. (2011, p.13)
explain the value of a model to the professionals involved,
From a
service perspective, providing staff members with a coherent strategy and
conceptual framework for understanding and addressing challenging behaviour, as
well as a strategy to manage risk and de-escalate behaviour during critical
incidents, while also maintaining their relationships with children in the
unit, is likely to be valued.
The
best knowledge available information provides a guiding framework, within which
to think about children’s needs. Macdonald et al. (2012, p.14) expands upon the benefits
for professionals of having a guiding framework,
There is value in
the argument that the principal value of a model lies in giving staff a
coherent “conceptual framework‟ to think about the work that matters. After all,
staff who can: think clearly and logically about their work use a set of
strategies to understand children’s behaviour and critically evaluate their own
actions and those of others use their understanding to act in the best
interests of children are likely to be better at their job than those who have
no framework……..They are also likely to have more job satisfaction and –
particularly when whole staff teams are trained in that framework – likely to
behave consistently, which is something we know that children value.
‘Import’ or Create a Model?
As mentioned, many different models have been created in recent
times. Although there are differences most models also have much in
common. This raises the question of
whether to adopt an ‘off-the-shelf’ model or create a unique local model. The former may have a
stronger evidence-base, being tried and tested. The latter may achieve greater
staff engagement and be more culturally sensitive.
I am
sure that both approaches can work well. My own experience is in developing
models that are unique but based on key research-informed principles. I find
that this leads to a high level of engagement, creativity and ownership. These models have achieved excellent outcomes
and wide acclaim. However, having a good model on paper is not a guarantee of good outcomes.
There are other vitally important factors that will determine success. For
example, quality of leadership, is the model embedded in the culture, is it
understood and do people feel a sense of ownership? It is the combination of all such factors
along with the model that determine the quality of outcomes.
In some
cases, an organization may have already developed a model over many years – but
have not fully articulated it. The task in this case may be more to do with,
·
reviewing the model
·
writing it up
·
and underpinning with research-informed theory
Continual Evolution
Once we have a model, we must
ensure it continues to evolve. Models must be alive and adaptive. They must be open systems and have feedback
loops, so they can receive the information they need from all parts of the
system. They must learn and develop from direct experience and wider
research. In other words, a model can
never become a fixed entity. As one part
of the system changes other parts must adapt. Continuous evolution is
essential.
For example, a change in the
external environment, politically, economically, or professionally will require
an adaptation. As with evolution, those that are most adaptive are most likely
to survive. In one organization I worked
in that had a strong model, we also had a working group every week to reflect
upon, clarify our practice and suggest ideas for improvement. This was then fed
back to the wider organization for further consideration. Just like organizations, a model is a living
system.
Outcomes
Willis
(2001, p.139) referring to the UK Department of Health initiatives of the
1990’s, states the centrality of outcomes,
Social care services are
likely to be most effective when they are orientated towards outcomes:
concerned with, designed, provided and evaluated in terms of the results
experienced by the people for whom they are intended (SSI, 1993, p.9).
The concept that services should
be based on ‘children’s
best interests’ has
become a touchstone for child and youth care practice
(Anglin, 2004, p.177). We need to have a general
idea of what the ‘children’s best interests’ are. This clarifies the outcomes that we aim to
achieve for each child. An outcomes
focused approach has a clear intent to deliver positive outcomes that can be
evidenced. As Department
for Child Protection (2009, p.3) put
it,
In a therapeutic
situation, it is essential that children and young people and the care workers
understand what they want to achieve, so that their goals and strategies for
achieving those goals are aligned.
Or as The
Department of Health (1998) succinctly state,
There is a need for clearly stated objectives of what the residential
care unit wishes to achieve. (In, Institute
of Child Protection Studies, 2006, p.20).
Kezelman and
Stavropoulos (2012, p.81) argue that given the complex childhood trauma
continues to be inadequately defined and covered by standard interventions, it
is important to focus on the outcomes rather than a ‘one size fits all’
treatment. To know what outcomes are
being achieved or not there must be a reliable and appropriate form of
assessment. Assessments need to focus on the most important outcomes and areas
of development. For example, how a child able to learn, to manage emotions and
make healthy relationships. Ward (2004)
makes two very important points about assessment,
1. You can have
assessment without treatment but you certainly can’t have treatment without
assessment.
2. What matters
most... is that the whole team is engaged both in the process of assessment and
in the process of treatment.
Overarching
outcomes and benefits of having a model
1. A clearly articulated model
clarifies the task and reduces confusion.
This leads to a higher level of congruence, with improved outcomes for
all stakeholders.
2. A model creates a shared
language and processes, which helps integrate different professional disciplines.
3. It is
highly beneficial for organizations to understand trauma and how to respond to
it. This is becoming trauma-Informed.
4. Greater
consistency and quality of professional and organizational development. Improved performance, funding and cost
efficiency.
5. The
development work is a helpful way of reviewing the organization’s culture and
practice.
6. The work
involved will be a positive experience of team building - creating a shared
vision, values and commitment. The
involvement of the organization in the creation process will lead to a high
level of engagement and ownership.
7.
A high-quality model will further consolidate
the organization’s position – in terms of being a high caliber service
provider, attracting referrals, funding and good quality staff.
8.
Holding a conference, publishing papers/book
all help to establish the organization as a leading authority in the field.
9.
In some
countries having a clearly articulated therapeutic model is becoming a
Government requirement, influencing the placement of children. Therefore, not
having a model could jeopardize an organization’s future.
Long-term and societal Impact
As well as benefits
to the young people, the organization and all those directly involved, there
will also be significant benefits to society.
The life-long prospects for the children’s well-being should be greatly
improved. They are more likely to grow
up into healthy adults, making a positive contribution to society.
Whereas,
children who are in care and who don’t experience an effective service are more
likely to have serious difficulties as adults, becoming a burden on society.
This is likely to be seen in areas, such as, poor health and early death, drug
and alcohol addiction, mental health problems, abusive behavior and criminal
activity. The ACEs study has made very
clear the potential long-term consequences of Adverse Childhood Experiences,
especially when there is no positive intervention (AAP, 2014).
Hannon et al. (2010,
p.162) illustrate this well in the graph below, from their research paper.
This graph compares
the costs of care for child A and B. Child B has a poor experience in ‘out of
home’ care. The costs associated with this child continue to escalate from the
age of 16-30 and will continue over a life time. Child A has a positive experience
of high-quality care. Initially, the costs for Child A are higher than for Child
B. However, by the age of 21 the cumulative cost is reducing and will continue
over a life time. The higher of the two Child A lines includes student loan
costs. The lower Child A line is without loan costs as they can be expected to
be paid back over a life time. The
initial higher cost for Child A is paid back over time as he/she begins to make
a positive contribution to society, through employment and taxes, etc.
This research was
carried out in 2010 and the actual cost numbers in £ are not so relevant. What
is relevant and applicable to any country today is the trend. Costs of a good
quality service with a therapeutic model will be more expensive in the short term.
However, in the medium term and over a life time, the financial cost is
removed. Whereas the financial cost of Child B continues to escalate, along
with the human cost and burden to society. This graph only shows until the age of 30, but
it is clear how the trend will continue over a life-time. As we know, deprivation and abuse tend to
continue in cycles, therefore the costs may well continue into further
generations. The cost effectiveness on
human and financial levels, of investing in the higher quality service is almost immeasurable.
The Lighthouse Foundation in Melbourne, Australia is one such example. I worked with them on the development of their Therapeutic Family Model of Care™,
Recently
an independent assessment was commissioned by Social Ventures
Australia to complete an analysis of Lighthouse Foundation’s Social Return on
Investment (SROI). It
proved for every dollar received Lighthouse returns $12 of social
value. (Lighthouse Foundation, 2019)
Process of change, model development and
implementation
This article has attempted to provide an
explanation of what a therapeutic model is and why it is important. It has implied the work that is involved but
not discussed the process of development and implementation, which is a whole
subject. The development process is fundamentally one of significant
organization change. It will be greatly valuable, but also challenging and
difficult. There will need to be processes such as supervision, training and
consultation to work through the issues involved. Some of this work will take
place before the model development begins and it can continue alongside. Without this work there is a greater risk
that the development project will be undermined.
Model development must take place alongside
processes that look at and work on the issues of change. The importance of strong leadership cannot be
underestimated. An organization that has developed a positive and effective way
of working, will need time to take that to the next stage and clearly define
their model. In my experience, a rough
guideline would be around one year to articulate the model and write it down,
another year to implement it, and a further year to establish it. The actual
timelines will be influenced by the organization’s stage of development, the
level of resources committed to the project and whatever challenges arise along
the way. When a model is achieved the
potential benefits that I have outlined are great. Bringing
people together to work on a key shared task can also have many benefits.
Given the immense challenges in this work, as Van
der Kolk and McFarlane (2007, p.574) have claimed,
This struggle to transcend the effects of trauma is among the noblest
aspects of human history.
References and Further Reading
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