Listen to thisFor many years now I have floated the suggestion to residential care and treatment providers that perhaps it is time to rethink what we mean by interdisciplinary. For decades, interdisciplinary has really meant some constellation of a handful of professionals. Typically, it means a psychiatrist as the clinical chief, perhaps a consulting psychologist, a few social workers, many Child and Youth Care practitioners, and sometimes it might include a nurse. In settings where young people with medical or neurological challenges are served, it might also include a speech and language therapist or an occupational therapist. What it all amounts to is an excellent team if the fundamental framework for residential services is constructed through a medical model lens. This kind of interdisciplinarity lends itself to clinical practices that aim to bring about behavioural change in young people and, on a good day, increased capacity in family systems to absorb the needs of a young person such that the family can, however precariously, be reunited and recidivism can be minimized.
This approach to interdisciplinarity has done very little to address some core realities in our service systems that perhaps have become more apparent in recent years. For one thing, the medical model approach is quite insufficient to address the needs, much less the desires, of diverse families and communities, given that this model is built almost entirely on Eurocentric, and fundamentally white, lived experiences and scientific knowledge. At least in Canada, it is no surprise that our services have always been problematic, and sometimes harmful, to racialized young people and their families and communities, particularly in the context of Indigenous and Black youth. But beyond this rather obvious incongruence between medical models and diversity, it is notable that this approach to interdisciplinarity has very little to offer in the context of relational practices; outside of Child and Youth Care approaches to care, the treatment model itself is not at all oriented to relational practices given that the professions involved, notwithstanding individual practitioners within those professions who might be relational, are themselves not built on relational practice concepts.
I want to start off 2023 by suggesting once again that we need to move into the 21st century, now nearly a quarter over. The good news is that we can do this informed by evidence. And the evidence suggesting that treatment ought to unfold through lenses that are quite far removed from clinical practices is mounting rather quickly and is in many cases far more voluminous and far more replicated than the evidence (largely from the 1950s and 1960s) that underwrites our current approaches. For example, there is a mountain of evidence demonstrating the efficacy of nutritional sciences in the promotion of not only physical health, but also self-regulation, cultural resilience, trauma mitigation, and antidote to behavioural (and also sleep) disturbances. There is also a large genre of evidence that demonstrates how the aesthetic context of a young person’s life shapes their self-esteem, their sense of autonomy, and their capacity for constructive activity and particularly for learning (both in school and at home). In fact, there is a substantial amount of evidence about the role of co-created aesthetics in pediatric hospitals in improving the quality as well as the speed of healing, both in the context of physical ailments and in the context of emotional wellbeing.
More than that, however, we know that the construction of mental health and neurodiversity as conditions in need of treatment is itself problematic, not only because the treatment thus imposed rarely works, but because this construction essentially dismisses strengths-based growth and human capital, including social capital, as sources of healing. In fact, virtually all emerging evidence produced by researchers and practitioners not bound or contained in eurocentrism and white supremacy point to the enormous power of intersectional identity, cultural heritage and pride, and community-focused social networks as fundamental building blocks of health, wellbeing, autonomy, and both individual and community growth.
It's not that the residential care and treatment sector has ignored the evidence altogether. Many service providers are increasingly investing in ad hoc capacity to respond to specific young people’s desires or needs with respect to treatment approaches that feature some elements of arts, music, food, cultural activities, and so on. What is clear, however, is that the sector as a whole has not moved an inch with respect to what really drives treatment; it continues to be a medical model based primarily on behavioural sciences and the demand for functional assimilation of those whose MADness or neurodiversity, often labelled through explicitly racist intellectual frameworks, challenges the structures and processes of mainstream settings such as schools, community spaces, and normative articulations of family dynamics. In other words, the psychiatrist, the clinical social workers, and the outcome and liability focused administration continue to rely almost entirely on an interdisciplinarity that most of the time is merely reflective of the presence of multiple disciplines substantively neutered through a hierarchical organizational culture in which the designation of who is in charge has never changed. I don’t know of a single organization in Canada where the approach to treatment is driven by cultural or identity explorations with medical services as enrichments when necessary. Any concept of healing that is not explicitly rooted in the medical sciences is ultimately limited to a supporting role.
This is not congruent with the 21st century. We no longer live in a world where the imposition of structure and control suffices to keep everyone either purposefully or inadvertently upholding the status quo of white normativity and the capitalist political economy. Instead, what we need are new constellations of knowledge and wisdom that cannot emerge from the interdisciplinary team that has built into it the constant reproduction of a singular worldview and way of being in the world. For this reason, interdisciplinarity has to shift in major ways that disrupt and transform exiting hierarchies with respect to treatment credentials. The 21st century residential treatment setting cannot be built on mid-20th century normative evidence. It must instead be built on and led by the postmodern, ever-shifting, and decidedly non-commodified immanence of the personal in social capital and the community as ecological frame. A small step in this direction would be to change up the interdisciplinary team. Here are three new disciplines that I recommend be considered as the leading force in case formulation, case management, and ultimately in the articulation of healing practices (rather than treatment practices).
First, every residential setting should have as its lead case manager a Residential Philosopher or a Traditional Knowledge Holder (TKH). As a professional discipline, the Residential Philosopher/TKH transcends the science-based evidence and relational front-line practice and instead shifts the work of treatment to a healing focus that is trauma-informed and built on the exploration of autonomy as the fundamental agent of growth for the young person. This inherently transforms residential treatment from its medical model to a setting in which young people learn to practice their autonomy using whatever resources they already have, including the inherent strengths of their intersectional identities and the possibilities emerging from cultural heritage and a strong view of cultural/racial futurism.
Second, every residential setting should have a Professional Community Builder. Such a professional discipline serves to build resistance and disruption to the institutional imposition of psychiatric order in the lives of young people. A Professional Community Builder works not with young people but with the world in which young people exercise their autonomy. Some aspects of this role currently exist in many residential service settings, where social workers or Child and Youth Care practitioners are tasked with finding and supporting family or kinship networks and connecting young people with community resources. These tasks, however, are constructed as supporting structures for the medical model. In other words, these tasks are carried out with a view of stabilizing the outcomes generated through medical model treatment approaches. They serve to reinforce the current case management model. I am suggesting to turn this dynamic upside down. The Professional Community Builder does not start with the recommendations of the medical treatment team, but instead works directly with community to establish the social capital context toward which the residential treatment team must work. The lead, therefore, comes from community rather than from the institutional treatment team.
Third, every residential treatment setting should have a network of professionals whose disciplines represent a range of possible orientations in relation to the any one young person’s way of being in the world. This means that case management includes not as an enrichment but as a decision-maker and overarching form of oversight someone who engages the young person, their family and their community in something that builds confidence and capacity for the collective exploration of how the young person’s growing autonomy can function without restrictions or normative chains beyond the residential setting. Sometimes this may be a professional musician; other times, it may be a sports coach, a food specialist, an interior designer, or a cultural mentor. The point is that the healing process for every young person in a residential setting is driven not by assimilation to normative structures, but by the full engagement of ways of being that reflect the young person’s self-constructed way of being in the world.
My point in proposing these three additions to the interdisciplinary team in residential care and treatment settings is not to suggest that these are necessarily and forever the right ones. Quite to the contrary, I suspect that just like the current interdisciplinary team became obsolete decades ago, the one I am suggesting likely will need adjustment in the near future. What matters more, however, is that we find a way of dislodging the universality of truth that is embedded in the formation of interdisciplinary teams that are neither (meaningfully) interdisciplinary nor political neutral. Moving our focus from treatment to healing means that we must think again about the ingredients of a healing process. Healing cannot simply be brought about through external interventions. Healing is a movement with multiple agencies that are primarily located in community but that interface with a young person’s emerging (and necessary) sense of autonomy. Facilitating such movement is far beyond the competencies of the current interdisciplinary team. New disciplines are necessary to respond to a world in which nothing is inherently true, and everything is a matter of how the individual and the social intersect, co-exist, and mutually reproduce one another.
So, there you go. A simple task for 2023. Time to change things up.
