Listen to thisChild and youth care, and specifically child and youth care related to out-of-home care, can learn a lot from elder care, long term care facilities and nursing homes. In fact, the more I engage with elder care, the more I realize just how much important learning we are missing in child and youth care by largely ignoring these important care settings where elderly people often spend the latter years of their lives. All the issues we talk about in the context of residential care, group homes, congregate care or whatever name we might give it, are well represented in care settings for the elderly. Some examples include underpaid staff, limited supervision, poor physical infrastructure, interprofessional practices and related hierarchies, behaviour, violence, mental health, developmental challenges, issues of dignity and respect, control, power, racism, oppression, and many more issues that might be categorized as challenging. At the same time, most of the more positive and generative issues are also represented, such as, for example, issues of voice and participation, self-determination and autonomy, play, hanging in and hanging out, being present, making moments meaningful, teamwork, collaboration, humour, love, and so much more. Both child and youth care and elder care settings are fundamentally relational settings, or, stated differently, settings where virtually the entire experience is a function of how we are with one another. And of course, there are moments where we are with one another in ways that are beautiful, life-affirming, and clearly congruent with the intuitive understanding of the term ‘care’. And yes, there are also moments when how we are with one another is unequivocally abusive, neglectful, and the cause of a great deal of pain.
In my experience, those of us involved in residential care for children and youth acknowledge that the care provided often could be better, but at the same time resolutely reject that the care we provide may be abusive. It is simply unimaginable to those providing the care to the children and youth that what they are doing might not be experienced as care but instead as abuse. Furthermore, we see ourselves protected from engaging in abuse largely on the basis of regulatory regimes and oversight, moral indignation, evidence-based practices, and the achievement of outcomes where the vast majority of young people we care for do not die while under our care (sadly, some do). This is very different from elder care, where the vast majority of elderly people do in fact die while being cared for by staff (personal support workers, nurses, social workers, and others). In fact, whereas discharge planning in child and youth care settings is narrated as strategies for meaningful and successful life-building scenarios (education, employment, housing, family, etc.), in elder care, discharge planning is generally quite undifferentiated from person to person – the plan is to die.
The question of relevance, in my view, is how we understand the concept of care. A related question is about the degree to which we accept elements within care that are resolutely not caring, but that can easily be integrated into and then complacently accepted as inevitable elements of care in the everyday experience of providing care, including the challenges, burnout, inadequate employment conditions, and difficult client interactions that are ever-present in that everyday experience. In elder care, these challenges are well known, well documented, and often even publicly discussed and lamented, but change is hard to come by. In child and youth care settings, resolutely uncaring activities and approaches are rarely in the public spotlight except when serious incidents- often child deaths - take place. Working with children and youth demands a forward-looking perspective in which we are constantly engaged in emphasizing the positive, the generative, and the possibilities of better practice, be that though greater applications of evidence-based practices or through reframing purpose and practice through lenses of trauma-informed practice, resilience, rights, and other strength-based narratives. And yet, what actually happens every day in child and youth settings is not all that different from what happens in elder care settings.
If one enters an elder care setting in Ontario (and I have done so in many other jurisdictions in the US, Germany, France, and elsewhere to similar effect), the first thing one notices is the sensory experience of the place itself. Rarely is that a positive one; the smells are off, the decorum is either worn or appears as very sterile and clinical, and the people one encounters do not exude joy. One might also note that the images on the walls, the objects in common areas, the food one smells, and the sounds one hears are hardly reflective of the usually quite diverse identities of the residents. Elder settings are of course much larger than child and youth care residential settings, and therefore often have a much more institutional feel. Nevertheless, as a sensory experience, entrance into elder settings is not different from entry into many (but certainly not all) child and youth care residential settings. Beyond the sensory experience, however, another thing one notices very quickly is that the majority of residents in elder settings are physically located in their room, usually by themselves, and usually seem bored, under-stimulated, or otherwise distant in their relationship to the space they occupy. Again, the much smaller settings in child and youth residential care give the appearance that this is not the case there, but a closer look and a systematic approach to keeping time still reveals that being alone, being isolated from social stimulation, being bored, and being disconnected from the place one occupies is a very common experience that takes up considerable time of living in residential care. While that may not always involve being in one’s room, program structures do impose such physical isolation frequently (such as quiet time, early bedtimes, time outs, or free time with no agenda), and where it is not physically imposed, it is nevertheless clear that many young people live significant portions of each day in their own heads and distant from their presence in place and in relationship.
Most significant are the interactions between care providers and residents. In elder care settings, these interactions vary from moment to moment and range in character from absolutely wonderfully caring and loving to distressingly abusive and neglectful. The reality is that elder residents are often yelled at, have their needs ignored, are made to wait a long time for responses for their requests, and are controlled by the work patterns of the staff rather than their own autonomous ways of being. It is often not evident that anyone really cares about the food that is served and its relationship to the person to whom it is being served. It is also evident that the conversations initiated by staff are often just an imposition of the staff’s need to express themselves and control the sounds of the setting rather than an equitable exchange of ideas or thoughts. In short, in elder care settings, it is evident that the setting itself belongs to the staff, that the culture of the setting is driven by the culture of the staff and the conditions of employment, and that the reliability of love and care is precarious.
I would like to say that this is not the case, or rarely the case, in residential settings for children and youth. But I am not sure that those of us providing care in such settings are quipped to recognize the patterns of behaviour that are far more evident in elder care settings. This is because we tend to assume our way of being in these settings as care providers is connected inherently and only to the process of care, and that any moments of abuse are exceptions and can be identified and dealt with quickly and resolutely. We assume that our valuing of children and youth pre-empts the appearance of abuse as another side of care. It is an interesting assumption to make, and relying on this assumption to differentiate child and youth care settings from elder care settings implies that we value elders less. The only meaningful explanation for valuing elders less is that they are in the latter stages of life and that our presence with them will necessarily be interrupted by their death. Given that, perhaps we take greater liberty with maintaining the ethos of care and separating it from the ethos of abuse. Perhaps this is why we are generally complacent about the not infrequently horrific experiences of highly vulnerable elders that are documented for us time and time again (noting especially horrific experiences during the pandemic). Perhaps this is also the reason why we readily allow elders to be counted as products with price tags in the context of private, for-profit elder care services.
The reality is that we accept that care for the elder in institutional settings, and particularly in institutional settings that are not designed for the rich and well connected, involves both care and abuse. This stage of life will be interrupted by death, so a little abuse to go along with a little care seems like a reasonable arrangement (I know this sounds horrible, but you and I both know that there is care and abuse in almost every elder care setting and we are doing nothing about it). The question then becomes how confident we ought to be that we have a different view of the stage of life of a young person. Will that stage of life not also be interrupted by death of the young person in the sense that the young person will cease to be young some day and therefore will cease to exist as a young person?
I have come to believe that meaningful training for child and youth workers involves at least some exposure to elder care settings. These settings have very similar mandates as child and youth care residential settings, and they similarly serve vulnerable people with limited power and resources to be autonomous human beings, with limited access to self-determination, and with a great deal of exposure to paid people in charge of making time go by from one day to the next. The value of seeing care in action but provided to a different demographic than children and youth cannot be overstated. I doubt that we would ever have enough courage to understand our practices of (institutional) care in child and youth care settings to inevitably be tied to abuse. But if we observe, and perhaps experience, care provision in elder care settings, and if we carefully and reflectively try to project what we see there to our own environments of child and youth care settings, I think that dark spot of abuse on our care product and practice would become visible much like a malignant tumour on our lungs does when seen through an MRI. And it is only when we see it and believe that it is there that we can do something to try and eliminate it.
