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Currently, there is a process unfolding in Ontario, Canada, that aims to find better ways of matching the profiles of young people with the type of services (mostly residential treatment services, but also other supportive services) they receive. The process is the result of legitimate concerns that some young people with especially challenging circumstances are poorly served in Ontario’s intensive care and treatment system. This part is certainly true. For many young people, appropriate or meaningful services seem unavailable, such that they either end up receiving no services until there is a crisis, at which point they’ll receive whatever service might alleviate the crisis, or they end up in residential treatment settings that are ill-equipped to manage and respond to their needs. With this problematic at hand, the system went to work to design a new system that supposedly will address these issues. I think it is important to observe carefully the dynamics and features of that newly designed system because the nature of this response is of relevance to jurisdictions far beyond Ontario.
The defining feature of what is being designed to address the service needs of young people is a way of classifying their clinical profiles, and then also classifying existing residential treatment providers across four levels, with the lowest level designed for young people with relatively straight forward treatment needs, and the highest level for young people with very complex and multi-dimensional treatment needs. One hoped for outcome is that residential treatment providers best equipped to serve young people with relatively straight forward needs serve only such young people, and those best equipped to serve very complex needs specialize in providing those services and don’t fill up their scarce beds with young people who don’t really need them. Additional features include adoption of evidence-based practices throughout the system but especially in the higher level service settings, a hub and spokes model whereby a type of ‘lead’ agency serves as the hub and therefore provides the most intensive and most expensive part of the services, and the spokes are community agencies filling in the gaps that are less intensive and perhaps more focused on connections to community, family, education, and social contexts, as well as perhaps transitions between service settings or between intensive residential treatment, step down services, and home.
There are many things to be said about this approach to system design. The first is that everything embedded in this design is based entirely on Eurocentric knowledge, and the prototype client and their clinical profile reflects a white lived experience. Notwithstanding extensive rhetoric in the design process about the importance of valuing different ways of knowing, and of being culturally responsive, the reality is that this rhetoric is entirely and completely disconnected from the design of the system and its operational mechanisms. This is a white system, which, in Ontario, is concerning given the well documented service disparities experienced by Black and Indigenous families and young people in particular, but also young people identifying as LGBTQ2S+ and young people with disabilities or neurodivergent young people.
Second, basing the design of a service system on the clinical profile of young people up front means that the entire system works from a medicalized/psychiatric perspective. Young people are constructed as damaged, but with the right evidence-based practices, we can undo or mitigate that damage. The model in use here is a ‘fix it’ model that aims to treat young people such that they score higher on various instruments at time of discharge. In other words, we are designing a model that seeks to confirm its initial clinical assessment. What it does not seek to do is to enable young people, their families and their communities to create an ecology of healing and being. Once again, the objectification of children is in full gear.
Third, the design of this system is based on fundamentally coercive assumptions. The idea that there are services that are equipped to handle complexity, and others that are not is measured on the bases of containment infrastructure. How many staff are there, is there a psychiatrist, can we impose medication regimes, and more. Underlying this way of thinking is the idea that more complex clinical profiles require more infrastructure, and since some service providers have more infrastructure than others, these are the ones that should lead the treatment. This is a fallacy; in fact, service providers with lots of staffing and high-status professionals at the ready, combined with the determination to implement manualized practices with high fidelity tend to be agencies that struggle with complexity; the best they often can do is contain and subdue. Practice evidence would suggest that how many people one can mobilize to contain youth whose life circumstances are complex is not at all an indicator of capacity. Sometimes it is the service providers with limited staffing, limited access to psychiatry, and limited use of manualized practices that find the connection not only to the young person but also their family and community.
Fourth, there is a certain naiveté associated with this system design that pretends the system is politically neutral. It is most certainly not. Across many jurisdictions, and certainly in Ontario, service systems are characterized by high levels of turfism. Organizations and service providers seek status, recognition, and funding in a competitive context, and individual leaders in organizations, although in my experience always committed to doing well by children and youth, are not free of personal ambition and accomplishment. The reality is that this system design aims to elevate some service providers as more highly qualified than others to deal with complexity. It seeks to institutionalize values that work to the advantage of some organizations, especially very large ones, and that generally revolve around psychiatric capacity, evidence-based treatment, and capacity for research and evaluation practices. It is naïve to think that this system does anything other than elevate the importance of the ‘hubs’, while constructing the spokes (community organizations) as small-time contributors that can handle only so much. This system is the domination of the large institution over the community by design.
Fifth, the system completely sidelines the knowledge and expertise of young people, their families and their communities. There is rhetoric about the importance of these groups, but the mechanics of this system are designed to function entirely without them. The experts are put at the front of the line, and it is their generosity upon which young people, their families and their communities must rely to get a word in edge wise. When we rely on clinical profiles for matching young people to specific services, we are by definition not relying on the young people’s lived experiences within family or community, and we are certainly not accounting for structural or systemic features of society, economies, and political structures that may shape those lived experiences. The only knowledge that drives decision-making is clinical knowledge held by clinical experts.
Last, but not least, putting the clinical assessment up front means that young people cease to be subjects in their own right, with autonomy, self determination, and growth based on their relational engagements inside and outside of the setting. Instead, young people are reduced to objects that can be measured, adjusted as needed, re-measured, and therefore improved. The system itself has no long-term vision of the lifespan of the young person or of their connections outside of institutional structures.
I could certainly expand on each of these six observations about the new system coming to Ontario. But the point is simply this: We have been talking about being with youth, their families and their communities differently, in ways that elevate their importance and that pair their wisdom and knowledge with that of experts. Instead, in the face of what is in fact a real problem (the lack of meaningful services for young people with particularly difficult or complex circumstances), we rallied around the very same systems of power, containment, and expert-driven social engineering we have had in place for decades. In that process, we work with the same assumptions we have always held, including the idea that there are some residential services or live-in treatment settings that are equipped to handle more complex situations than others based on the person power brought to bear. I would argue quite to the contrary that we continue to have residential services that rely on power and control to subdue behaviour symptoms, but with the right kind of framing we now call this evidence-based practice and locate it firmly within the realm of treatment. These are precisely the kinds of programs that create the barrier for meaningful service for young people encountering real complexity in their lives, which is almost never a function of their clinical profile alone. Instead, it is almost always a function of how the world around them interacts with who they are and how they need to be. Yet nothing in this new system is meant to address any of this. In Ontario, we are going all in on psychiatry as the answer to many young people’s challenges. This is a profound shame, and it is also shameful that we are doing this while talking about relational practice, care, love, autonomy, self determination and different ways of knowing. With this new system, Ontario is saying goodbye to any pretense of community; our future is institutional.
For jurisdictions around the world, Ontario’s new approach (which is not new at all) will be presented as innovative and the latest thing in system design. I would encourage those engaged by the representatives of Ontario to ask some serious questions about how what is being created now differs from what we already had. More importantly, this process raises questions about how we might move toward change in mental health, residential service systems, treatment modalities, and healing processes. Clearly, doubling down on the same old ways of knowing and being is not going to change a thing.
