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134 APRIL 2010
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RESIDENTIAL CARE

Working to make sure professional procedures do not lead to the institutionalisation of children living in children's homes

Jane Kenny

In this, the first of two articles about institutionalisation in residential child care, Jane, illustrating her argument with a poignant case vignette, introduces the paradox of the tendency for working procedures – which are generally considered as good practice – to lead towards institutionalising life in a children's home. You can read the second article HERE

Residential child care has – justifiably in some instances – come in for its fair share of criticism over the last twenty years or so. (Shaw, 2007) There has been a growing move to view substitute family care as a better option for children unable to live with their own families. The argument made is that residential child care leads to the de-personalisation of children and to their institutionalisation. Those with this point of view argue that residential child care does not place due value on the individuality and uniqueness of children and young people.

I am of the belief that residential child care for young people can be more beneficial for some young people than a substitute family setting. I am aware that there are children and young people for whom temporarily at least, substitute family life is too threatening. In this group I include those children who may not be able to live with their own families but who feel love and loyalty towards them. I also include those who may have had one or a number of unhappy experiences in foster care. For these children I believe sensitive and planned residential care can be of great help. It worries me therefore that there are aspects of residential child care which make it difficult for those of us who work in a residential child care setting to avoid making it an institutionalising experience for the young people.

I’ve worked in a children's home for four years and one of the biggest challenges for me still is trying to “normalise” the experiences of the young people in my care. It seems to me that the policies, working procedures, legislation and care standards which are in place to may give us professional guidance but can also work to make the process of “normalisation” all too difficult to achieve (Department of Health, 2002).

Our aim for the young people who come into the care of the children's home I work in is to provide a quality of care which replicates as much as it can “good enough parenting” and to build relationships between the young people and staff based on this premise (Winnicott,1953). We try to offer care and meet the needs of the young people holistically and therapeutically while cherishing each young person's individual identity.

It has long been accepted that institutionalisation tends to de-personalise the institution's residents (Goffman, 1961). My major argument in this article is that our working procedures make it hard for residential child care workers to pull away from the process of insitutionalisation. In this article I focus on the problems created firstly by the limitations of staff rota systems, secondly I consider how poor efforts staff recruitment and staff retention can influence the quality of care provided by creating feelings of loss and abandonment. Finally, using a case vignette, I argue how what is deemed to be good professional communication can be a factor in de-personalising and institutionalising life for a child in children's home.

What I mean by institutionalisation
At this stage I would like to make it clear that when I use the word insititutionalisation I am thinking of a wide range of phenomena but in general I would like the reader to understand that I mean the process in which a person living in an institution (in this case a children's home) directly or indirectly accepts and conforms to aspects of the institution's control to the extent that the needs of the institution are seen as more significant than the needs of the individual resident. For instance in this might be included the need to look after a number of people with the least amount of staff. The process of institutionalisation tends towards a loss of individual identity and towards the individual’s de-personalisation and towards alienation from peers in the wider society (Goffman, 1961).

The impossible task: creating an effective staff rota system
The aspect of residential child care which in my view is most influential in making children's homes institutionalised is the necessity for the care provided to be governed by a staff rota system.

It would be easy for the casual observer to conclude that the kind of communal care provided by residential child care workers is not consistent with the idea of “good enough” parenting (Winnicott, 1953) because it can seem to be at the mercy of staff routine and staff needs.

On the face of it these doubts may be evidenced at the children's home I work in. Having up to 10 residential child care staff means that the young people have 10 different people working at different times to meet their needs. A young person in their family home would usually have two main caregivers as the parenting figures. Having ten different people giving parental care obviously increases the chances of inconsistency in the care the young people receive. Having to meet and become accustomed to so many adult figures can be confusing and disorienting for young people. In the children's home I work in we try to reduce the negative aspects of this by giving each child a special worker, a “keyworker”, whose responsibility is to focus on building up a relationship with the young person and to be an adult the young person can refer to at all times and who has specific responsibility for ensuring the needs of the young person are met. Unlike natural parents, keyworkers, do not have an opportunity to care continuously for a young person. This can mean that the young people can experience the absences of a member of staff they feel attachment towards as re-enactments of the loss, rejection and abandonment they experienced earlier in their lives and which are the principal causes of the anxieties, fear and anger they often display to staff when they are first placed in a children's home. So, at our children's home we feel it is important to ensure that a staff rota is devised in a way which tries to ensure that keyworkers are there for children on a regular basis and especially for significant events such as birthdays, parents' evenings at school and care plan review meetings. We also try to create a rota which ensures that staff are not absent for long periods of time, except of course when they are on annual holiday. During a keyworker’s annual holiday the young person is given another member of staff who has the responsibility to take on the key working responsibilities while the actual keyworker is away. With the possible and in reality probable event of staff shortages and staff illness these compensatory strategies can be stretched. This is why in my view staff recruitment is crucial to achieving a consistent and sensitive caring environment in a children's home.

Retaining staff
The anxieties created by these re-enactments of earlier loss, abandonment and rejection which I discussed in the previous paragraph can be made worse for young people placed in children's homes by staff leaving the home. Retaining staff in what can often be the highly emotionally charged working atmosphere is a challenge to those who manage children's homes. In our children's home we have made efforts to avoid a high rate of staff turnover and so limit the possibilities for inconsistencies in care. We work very hard to recruit the right staff and we are intent on keeping them. During the interview process we endeavour to ensure that applicants have resolved or are effectively coping with any emotional issues from their own past. We have found that if we appoint staff who have not done this, they struggle because they over-identify with the young people’s difficulties and so they can’t cope with the young people’s anxieties. We also attempt to recruit staff who understand and accept young people’s needs for consistent, committed care. Having done this, we place a great deal of emphasis on implementing a staff development strategy which provides each member of staff with regular supervision and continuous training in child development and child care. We do this to show staff that they are valued and to give them a sense of professional esteem. Appointing and retaining staff of this calibre can be difficult. The status of residential child care in the ranks of different professional roles is unjustly low.

The difficulty of achieving sensitive and effective information sharing
In a family the information about a young person is usually only shared by two parenting figures, while the institutional necessity of having a relatively high number of caregivers in the group living setting of the children's home means that information about the young people is shared by however many residential child care workers there are employed in the home. This number is added to by social workers, teachers, health workers, counsellors and so on. With this size of social network it is easy for information that is emotionally significant for the young person to be lost in the professional drive to ensure that everyone is communicated with. Here I am not arguing against the need to communicate but arguing that the content and quality of communication is paramount. More importantly for the young people, particularly when they are new to the children's home, we need to be aware at all times how disorienting and threatening it can feel to a young person that so much of their personal information is held by adults who are strangers to them. In my experience young people also find it irritating and stigmatising that (unlike their peers who live with their families) they have to repeat personal and often painful information about their lives to more and more adults from different professional disciplines.

Mary
Mary, a fourteen years old girl who was placed at a children's home where I worked had a history of self-harming. When under severe stress she would cut her arms with pieces of broken glass. For a number of years before being placed at our children's home, it was thought that Mary had been the victim of physical and sexual abuse perpetrated by her stepfather. Although frightened of this man she had plucked up the courage to tell her mother but her mother did not believe her. Soon after this Mary began to cut herself. As a consequence of her self-harming, Mary’s GP referred her to a psychiatrist at her local hospital who saw her for two years. At the same time Mary’s stepfather left the family home and her self-harming stopped. The psychiatrist discharged her. However Mary’s relationship with her mother deteriorated. She acted angrily and with physical aggression towards her mother. Her mother blamed Mary for her stepfather leaving the family home and Mary was angry that her mother would still not believe her about her stepfather’s sexual and physical abuse of her. Mary’s mother referred her to social services because she believed Mary’s angry and aggressive behaviour was influencing the behaviour of her young brother and sister. It was felt that work to address the problems of the family could only be done if Mary was for a time withdrawn from the family. Soon after she was placed with us Mary returned home for a weekend visit. She found her stepfather there and after an angry quarrel with her mother she returned to the children's home. That evening Mary began to self-harm again. When I talked to Mary about what had happened she did not talk directly about her stepfather’s return to the family home but about the fact that everyone seemed to know about her. Mary felt she was always being asked about how she was, what had happened to her and was always being told why she had to stop cutting herself.. She said she felt everyone – teachers, staff at the children's home, doctors, nurses and the police – was looking at her. It seemed to Mary that everyone thought there was something wrong with her. Everyone seemed to need to know about all the things she had done and that she had to stop doing it or something would have to be done about it. While I do not for a moment believe any of us intended this consciously, I think Mary what Mary was saying to me was that while we – all the professionals – were busy fussing over about what to do in response to her last piece of unacceptable behaviour her feelings were being lost and not heard.

Mary’s story is an example of how in tripping over each other to communicate information we can forget that one of our primary professional functions is still to provide “good enough caring”. In order to defend ourselves professionally “to make sure that she did not do more serious harm to herself “we were inadvertently institutionalising her by seeing her only as a physical being but not seeing her as an emotional being too.

In this article I have focussed on how residential child care work, governed as it is by staff rota systems, low staff retention and the professional need to communicate, needs to give these issues more consideration than they currently are if the care system is to provide children in residential child care with the sensitive and individual care that we promise to give them and that they need.

In a later article I will consider how official documentation and nationally laid down procedures and standards can act as obstacles in the way of providing “good enough” care to children who are placed in residential care.

References

Department of Health. (2002) Children's Homes : national minimum standards, children's homes regulations. London. Department of Health.

Goffman, E. (1961) Asylums : Essays on the Social Situation of Mental Patients and Other Inmates Harmondsworth. Penguin, 1968 National minimal standards.

Shaw,T. (2007) Historical Abuse Systemic Review: Residential Schools and Children's Homes in Scotland 1950 to 1995. Edinburgh. Scottish Government.

Winnicott, D. (1953). Transitional objects and transitional phenomena. International Journal of Psychoanalysis, 34. pp. 89-97.

This feature: Kenny, J. (2007). Caring Times. Republished here with permission from goodenoughcaring.com

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