ListenOver the past three months, I have contributed a series of propositions about quality in residential care and treatment settings, suggesting that the variables that matter most are things like Sleep, Food, and Community, amongst others. I confess that the way I speak to quality in residential care and treatment settings is quite different from the focus that is often present at more formal gatherings of stakeholders in this sector, and it certainly does not correspond to how governments and regulators want to see quality manifest. Almost always, those conversations turn to evidence-based practices, metrics about outcomes, and quite rigid surveillance and accountability systems. Why am I not buying into these conversations?
Perhaps it isn’t obvious, but it certainly should be understood that conversations about quality care or quality treatment (often, these things are not distinguished despite being very different things) are never politically neutral. Regulators and governments are not all that interested in what actually happens in residential settings, so long as a few things are in place. These include: 1) safety, by which I mean the physical safety of children and youth such that there are no reports of child death or media coverage-worthy injury; 2) related to the first point, mitigation of risk and liability feature very high on government priority lists; 3) enough safeguards to avoid scandals, such as hiring staff with sexual abuse records or financial misappropriation; and 4) authority of recognized experts and expert professions, most notably psychiatry. These things are of great interest to government because the investment in residential care and treatment is significant and there is a public expectation of children and youth being treated to get healthy and productive.
Many conversations about quality, including ones that child and youth care as a field has increasingly been participating in, are really conversations about reinforcing these government priorities. Individually, each of these priorities seems quite reasonable. None of us would want children and youth to be unsafe, or for there to be many child or youth deaths and injuries (although there are many such deaths and injuries in most geographic jurisdictions), and certainly we all agree that we don’t want sexual offenders working with our children and youth. What is less obvious is the collective impact of pursuing these priorities under the guise of conversations about quality.
The operationalization of these four priorities does not bode well for a child and youth care approach to residential care. There are several nuanced dynamics at play here that I can only sketch out briefly for now. First, the nature of quality that is being pursued under the guise of quality care is not actually oriented toward care at all; one might even suggest that it is anti-care. What is desired instead is to align the operating logic of residential care and treatment with the operating logic of an existing system that is already familiar to the public – the health care system. The focus on clinical indicators of growth and improvement ensures that we increasingly construct the children and youth as patients, or passive recipients of medical care overseen by medical experts such as psychiatrists. It also means that just as in the health care system, most of the actual care being delivered is devalued. It is delivered by the largest workforce in the system, which are child and youth care practitioners. This is an essential workforce, but each practitioner is entirely expendable. Furthermore, to the extent that medical interventions still require someone to be with the young people in the evenings and on weekends, maintaining a cheap and easily redeployed workforce outside of any regulatory structures is brilliant and further cements the importance of regulated professionals (such as psychiatrists) as overseers of treatment. So long as quality is defined in clinical terms, child and youth care practitioners are maintained as a mass workforce with no power or authority at all.
Safety, particular in the physical sense, is another way in which the political priorities start to shape our practices and devalue our care work. The obvious way to achieve physical safety is through control and containment, including forcible confinement. These days, such control and confinement manifests in different ways. This includes, for example, ensuring two or more staff are serving as ‘one-to-one’ for a young person who poses risks to the system. While the rhetoric of community-based treatment continues unabated, the reality is that many youth live in community settings but experience the four walls of custody as cheaply procured one-on-one staffing surrounding them and controlling their every move, all in the name of quality.
From a government perspective, the risk of something going wrong as children and youth are placed in residential settings is far too high. The way to mitigate that risk is to create considerable distance between the regulatory frameworks (for which governments are accountable) and everyday practice. The best and most sustainable way to achieve this is through privatization. So long as all practice unfolds through private (often for-profit) entities, governments cannot be held fully accountable and responsibility for problems is quickly shifted to the private sector. Note that from a government perspective, critiques of private for-profit motives are plentiful, and so long as the focus does not shift on governments, the goal has been achieved, again in the declared commitment to ensuring quality in residential care and treatment and in out-of-home care more generally.
In short, we must be careful about jumping into conversations about quality that have as their main drivers satisfying government priorities. We may end up inadvertently devaluing the high-quality work that already unfolds in residential care and treatment every day across Canada and the world. It is precisely the approaches to quality care that are central to child and youth care practice, such as relational practices, a focus on self and the development of the self, a strong commitment to child and youth voice, and an orientation to honouring the family and community networks where young people originate and identify belonging, that are at risk right now.
What we need are not conversations about quality but quality conversations about care. Such conversations should be informed by multiple epistemological and methodologic frameworks, and they should account for young people’s ways of being in the world and their connections to others, to land, to spirituality, to identity, and to community. Otherwise, we might be surprised to learn that what we thought was a journey for higher quality care turns out to be a journey to eliminate all traces of child and youth care practice and the themes and issues important to us.
