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127 SEPTEMBER 2009
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Personal Care and Treatment Planning

Gale E. Burford


Over the past decade or more, changes have occurred with respect to criminal justice and social welfare institutions which have had a profound impact on group care practice with children on both sides of the Atlantic. These changes have been brought about in part by economic conditions, by advances in technology, and by alterations in the legal codes of most parts of the United States, Canada, and Great Britain. The evidence of change can be found in the diverse language contained in the group care literature, such as: protection, remediation, rehabilitation, life skill development, care, control, punishment, education, re-education, special education, retraining, treatment, and therapy. Any attempt to understand the needs, wants, and problems of young people in receipt of group care services is a complex undertaking. This is particularly true with respect to young people who are referred because of identified or predicted threat, delinquency, acting-out, disturbance, or maladjustment.

In this chapter, consideration is given to a number of contemporary trends in behavioural management, the provision of education and social opportunities, and the offer of treatment to troubled and troublesome young people. It is argued that personal care and treatment can only be understood if assessment and evaluation methods are sufficiently precise as to account for important differences between: the variety of care and treatment programmes, the setting in which these services are offered, the differential characteristics of young people admitted, and the varying levels of involvement with respect to families and local communities. To meet this challenge, any approach to personal care and treatment planning is dependent upon the use of a differential assessment typology. In what follows, research findings based on the results of one such typology are summarized, and implications for group care practice are discussed.

Background and assumptions

Behavioural management
The impact of economic recession and the increased emphasis on individual rights and responsibilities for children have supported the social policy notion of accounting for minimum standards of, care. Generally speaking, such standards involve guarantees of personal safety and security in both physical and emotional terms. In practice, physical safety and security have been translated to mean: freedom from attack or access to protection when threat is perceived; food, clothing, and shelter; and rest or stimulation based on physiological needs (e.g. large muscle exercise). Emotional safety and security have been taken to include: the need for physical space in which items of personal symbolic worth can be stored, where feelings of worth can be nurtured or tension internally governed; and the need for sufficient social stimulation as to prevent psychological withdrawal.

While such minimum requirements may be administered in stark terms by group care practitioners, research (Moos 1975) supports the notion that lower rates of absconding and other rule-breaking behaviours are associated with the level of satisfaction reported by residents about their living unit environment. Moos’s cogent statement summarizing research in residential group care bears repeating:

“There is no reason for not converting the large proportion of control oriented programs in correctional and psychiatric settings into treatment oriented programs of the appropriate types. This would at the very least, enhance the satisfaction and morale of the residents and staff who live and function in these programs.” (Moos 1975: 129)

While trends in the rights and responsibilities of young people have sought to follow the principle of least interference, economic conditions have required that the methods used be cost-effective. At the same time, influences from learning theory (Bandura 1969), field theory (Lewin 1951), and the theory of symbolic interaction (Cressey 1965; Mead 1974) have found enhanced expression in group care practice. This has resulted in an expectation that behaviour to be managed will be specified more clearly, that important variables in the person-environment context will be isolated, and that more insightful use will be made of peer group influences in behavioural management.

Research shows that positive behavioural changes can be effected with many residents in a range of different types of programmes (Gendreau and Ross 1979; Lipton, Martinson, and Wilks 1975; Ross and Gendreau 1980; Taylor and Alpert 1973). However, one is left with the impression that most youngsters do not maintain acquired changes following release from group care services. This is particularly so when all residents and all programmes are aggregated together for evaluation purposes, regardless of the important differences between them. In spite of widespread acceptance of the notion that behaviour is a function of a particular person in a particular environment, most research has grouped all residents in all programmes together using the same measures of progress. Jones’s (1977) summary of research on the social, psychological, and physiological effects of expectancies, Bronfenbrenner s (1979) review of ecological variables and Moos’s (1975) work on social climates all reveal the complexity which must be taken into account in any study of reciprocal relations between people and environments.

The provision of education and social opportunities
If nothing else, children and young people continue to age during their period of placement in a group care centre and continue to share the same requirements as other young people living in the community. In addition, many young people in receipt of group care services also have problems with learning, and some have a variety of physical and emotional problems, such as allergies, nutritional deficiencies, enuresis, and motor disturbances. While these problems do not appear to be valid predictors of behavioural problems, clear associations are evident (Hippchen 1978; Sapir and Nitzberg 1973). Arguments have been put forward for a decade or more that educational, social, and health-oriented services could solve the problems which bring children into care, or at a minimum such services should be provided to prevent children and young people progressing further into anti-social behaviour. Structuring time through the use of pro-social activities and pursuits has become virtually synonymous with the term programme, especially in the North Americarn context. That such activities represent forms of social control or behaviour management must be recognized, even though it is important to recognize that the same services are used to enforce social control for young people not in care.

Research has shown that considerable gains in skill development, academic achievement, and improvements in attitude may be made during periods of group care and treatment. However, these gains cannot be associated globally with measurable success in subsequent school performance, job stability, or reduced recidivism (Gendreau and Ross 1979; Lipton, Martinson, and Wilks 1975; Ross and Gendreau 1980; Warren 1983). Once again, as in the case of behavioural management, such findings may simply reflect problems in measurement as much as anything else, especially in those studies which group all residents in all programmes together for evaluation purposes. Thus, there is no rationale for failing to provide the usual social, health, educational, and legal opportunities and services, unless it can be shown that these tend to introduce other types of difficulty for children. Even if such services caused harm, it is still difficult to know with whom the services are harmful and under what conditions this would occur when different types of youngsters and programmes are evaluated merely in global terms.

The term treatment is used here in a manner which is synonymous with the execution of a plan of intervention, the purpose of which is to influence the youngster to make pro-social decisions in the future. In this sense, for a service to qualify as a treatment per se, expected outcomes must be stated beforehand, noting what the service intends to do and what outcomes are anticipated. Regardless of whether the results are beneficial, credit cannot be given to treatment unless the preceding conditions are met. The need for rigour on this issue cannot be overstated. Without an explicit statement of intent or plan, it is impossible to distinguish between actions which are initiated primarily in the service of social control, those which are initiated in the well-intentioned belief that something “ought” to be good for a youngster, and act ions which are based on a testable hypothesis.

This definition can be said to apply in settings where the desired outcomes may focus on symptom reduction and other specific behaviour changes, as in the case of criminal justice settings where social policy has emphasized recidivism as the measure of success. Perhaps this stringent demand is related to a social perception that juvenile delinquents are “less deserving” than other groups of children and young people. Such a definition of treatment does not exclude any effort – therapeutic, educational, environmental, ecological, etc. – so long as that effort yielded an explicit and testable plan beforehand. While some research indicates that many individuals make positive changes during treatment, it is also clear that recidivism rates and the future expression of behavioural symptoms remain. Once again, a general conclusion is that the majority of young people do not maintain positive changes once they leave treatment.

Differential treatment
One of the most widely publicized reviews of treatment effectiveness with delinquents in the United States carried out before 1967 (Lipton, Martinson and Wilks 1975) stands as a rich source of information supporting many treatment efforts, even though conclusions reached by these authors had the opposite effect. The “nothing works” argument (Martinson 1974) portrayed the failure of treatment when all the subjects and all programmes of care and treatment under all conditions were taken together. Others (Jesness 1975; Moos 1975; Palmer 1978; Ross and Gendreau 1980) have argued that programmes of care and treatment are not all the same and that when certain differences are taken into account, some treatments do bring about success with some subjects, under certain conditions. There is, therefore, adequate justification for continued practice, careful evaluation, and research.

Neither the “nothing works” arguments nor the judicial moves to ensure “fair practices” impede treatment necessarily, so long as “fairness” allows for public and private purchasers of service to choose a particular treatment that is known to decrease the likelihood of recidivism or future recurrence of a problem. Eventually such practices might encourage families and others to become more involved in choosing which services are best for them and the possibility of moving to an alternative service if a better option is discovered (Moos 1975). Masked in statistics and data on outcome are findings which can only be understood if one takes account of certain differences among the young people who come into care, their families and perhaps communities, programmes of care and custody, treatment methods, techniques of evaluation and research, and the characteristics of counsellors, educators, and care staff.

Researchers have noted the masking effect that occurs when programmes (or courses of action) are evaluated with all the human subjects grouped together (Gendreau and Ross 1979; Grant and Grant 1959; Hunt 1971; Jesness 1965, 1971a; Palmer 1978; Quay 1977). At the same time, attempts to control for these variables across settings, while continuing to account for the unique experience of individual subjects presents one with all the same problems as confronts other research on human behaviour in a social context. What constitutes individual counselling, group or family therapy, life skill development, and even behaviour therapy varies between settings and practitioners. Elsewhere in this volume consideration is given to the organization, provision, and evaluation of group care services for children, whether involving the education, health care, criminal justice, or social welfare resource networks. The subsequent focus of this chapter is on care and treatment planning for individual children and young people who are prone to be admitted or readmitted to group care in the criminal justice or social welfare systems.

One last word, however, is required by way of introduction. This is, that while an understanding of the interplay between people, settings, and conditions is still in its embryonic stage of development, group care centres cannot back down from the requirement that each will operate from carefully written descriptions of the services they offer, preferably written for each individual living-unit.1 Some programmes so lack a sufficiently detailed explanation of what they offer that they fail to inform managers and practitioners about whether the mandated service is actually being provided. Other programmes may have clear descriptions of intention but lack the resources and capability as to maintain outcomes over time (Quay 1977) or to monitor “program drift” (Johnson 1981).

Differential assessment and research

In an ideal world, group care practice might include provision for a unique care and treatment plan which would fit the special requirements of every individual in receipt of services, with any problem in every situation. However, approaches which are individualized to this extent contribute little to our understanding about effective ways of allocating resources to youngsters whose problems, situations, and perceptions are similar. At the same time, individualistic approaches serve merely to complicate the task of conceptualizing programmes of personal care and treatment. Even though some writers support the idea that important differences are to be noted between children and their families, and between programmes (Apter 1982; Maier 1979, 1981; Whittaker 1979), there is less agreement about which differences are important for planning group care and treatment. There is also little agreement about which characteristics are the most significant influences for individual children and families. Still, there is probably more support for a differential approach to group care practice than for approaches which operate on the assumption that a single or simple solution can be found to service the needs of broad categories of children and young people.

Differential assessment and research inevitably involve the use of a conceptual typology which is used to classify information about a person with a problem in an environment. Such classifications with human subjects must never lose sight of the fact that a typology is merely a starting point against which a decreasing application of a label is measured (Toch 1970). If a typology is used, the rationale for its use must be stated beforehand to avoid any confusion about what the various activities associated with classification actually mean (Levinson 1982). For example, assignment to a group care programme can easily be for control purposes rather than treatment, or such a placement might be to take advantage of or avoid some other service, such as prison. It is assumed in this chapter that assessment typologies are used with the aim of matching people with appropriate resources. In so doing, assessment typologies can only be used to develop optimal resources if they withstand the demands of scientific rigour. In reality, it is probably more accurate to suggest that one seeks to find a “good enough” fit. The “good enough” or minimum requirements approach should not impede the development of treatment approaches so long as consideration is given to the satisfactions of life in each resident’s daily routine. Minimum standards may be applied to ensure that the overall quality of life for residents is maintained, and to ensure the quality of specific goal-directed activities, such as recreation or counselling.

Rather than to single out any one assessment typology as being the best, suffice it to say that the choice is a complex one depending, of course, on the specific purpose and the cost, balanced against the demands made on the setting, including demands associated with the social policy mandate imposed externally (Fulcher 1983). In selecting an assessment typology the following considerations should be made at the very least (Megargee 1977):

While many assessment typologies have been tested, ranging from head shape to psychiatric disorder, fewer have evolved in conjunction with rigorous evaluation as to their reliability, validity, and social desirability. Others, such as the Moral Development Scheme (Kohlberg 1964, 1969), the Minnesota Multiphasic Personality Inventory (Megargee et al. 1979; Meyer and Megargee 1972), and the Conceptual Level Matching Model (Brill 1978; Hunt and Hardt 1965) show promise in their capacity to guide care and treatment efforts with rigour. However, each of these typologies has not been used extensively enough as to guide practice in a variety of settings. While it is tempting to infer differences which two systems might describe, verification of such differences must be left to rigorous cross-classification studies. There are some behavioural systems (Jesness 1971a; Quay and Parsons 1970; Quay 1977) which have demonstrated relevance in developing care and treatment programmes and measuring outcome, but these seem to be less revealing when used independently of other measures. Alone, each typology does not account for which person made what changes, in what circumstances. It would seem that typologies based on personality still offer the most reliable and valid methods of highlighting personal variables in this equation.

One of the most extensively used assessment typologies based on personality characteristics is the Interpersonal Maturity Classification System: Juvenile (Warren 1966). Research with this typology has yielded a unique compilation of behavioural, demographic, and psychological data about juvenile delinquents in general and those in group care and treatment in particular. This typology has been used to support personal care and treatment planning, programme development and research in residential and community settings involving families, family group homes, boarding homes, institutional facilities of various size for all levels of security, day centres, classrooms, and other short-term reception and detention centres. The practice research findings associated with these efforts will be summarized below as they relate to the role of group care centres and to the development of personal care and treatment plans. Before doing this, however, it should be noted that the Interpersonal Maturity (I-Level) typology was developed in the main for delinquent adolescents and young adults. Certain implications are evident for the education and treatment of other troubled young people and these will be noted where appropriate.

The Interpersonal Maturity Classification System: Juvenile

What is comparatively unique to this typology Is that while the maturity levels represent theoretical descriptions of normal development, the behavioural descriptions are associated with empirical differences identified between different young people assessed to be at the same level of interpersonal maturity. Nine different sub-types of delinquent young people (Warren 1966) and three sub-types of non-delinquent young people (Harris 1978) have been described using this assessment typology. While some of these descriptions are based on larger numbers of subjects than others, each has relevance for practice in a number of settings. For example, it would seem that lower maturity young people are likely to be referred to health care, special education, or other social welfare services rather than to criminal justice or correctional settings. The primitive and unsocialized manner of presentation which is characteristic of lower maturity young people is comparatively obvious and is probably more understood by practitioners who deal with severe child neglect. Care and treatment strategies have been developed for lower maturity young people in both residential and community settings with positive results (Warren 1983). The majority of young people assessed with this typology can be summarized within three subgroupings: passive-conforming, power-oriented, and internally conflicted young people (Palmer 1974).

Passive-conforming young people

Described as middle maturity,

“This type of young person usually fears, and responds with strong compliance to, peers and adults who [they] think have the “upper hand” at the moment, or who seem more adequate and assertive than [themselves]. [They] consider [themselves] to be lacking in social “know-how”, and usually expect to be rejected ... in spite of [their] efforts to please [others].” (Palmer 1974: 12)

An example may be found in the case of a sixteen-year-old boy who came from a home where he was treated one minute as though he were much younger than his actual age and the next minute with physical terror. The youth was brought before a juvenile court having been found with burglary tools in the security area of a large office complex at night. When apprehended, he acted as though he had been a “bad boy” and co-operated with the arresting officers by showing them where his friends were hiding on the fire escape waiting to be let into the building. The nature of his interpersonal maturity was revealed further at the police station when he discovered that his friends were angry with him. At this point the boy began talking under his breath and acting belligerently about being arrested. When challenged by one of his friends and when given a knowing glance by the arresting officer, this boy made a daring escape from the police station while the other boys were waiting. A crisis was precipitated for this youth in the form of a conflicted set of allegiances, leaving him – in his view – with no way of conforming to both.

Although important differences have been found between youngsters in this assessment subgrouping (Palmer 1971), the general pattern of acquiescence to power, coupled with what has been described as a “soft” exterior or affect is usually evident. As for goals of intervention with this group of young people, both behavioural management and the provision of a number of other services are feasible under a variety of conditions. Care and treatment efforts aimed at reducing recidivism have ranged from moderate success to outright failure (Jesness et al. 1972; Palmer 1974; Warren 1983).

Behavioural management goals in group care practice are comparatively easy to accomplish with these youngsters because of their adaptability in a variety of settings with different types of young people (Jesness 1971a; Palmer 1972, 1976). These young people also offer apparent satisfactions for staff who work with them as reported elsewhere in this volume with Fulcher.

Behavioural management tasks may be carried out as part of a general yet supervised programme of activities emphasizing consistency, attachment, firmness, and caring. More important than any single method or technique of behavioural management is the pressing need for any care and treatment plan to reduce the sources of fear, threat, and anti-social influences in these young people’s environment. For example, passive-conforming young people would seem to respond to group activities, team sports, clubs, and other pursuits involving physical activity. When levels of structure and certainty are reasonably high, these young people are willing to co-operate. This factor, plus their being likeable and amenable to supervision in groups, can present risks if passive-conforming young people remain too long in institutional care or are not challenged sufficiently as to overcome their vulnerability to delinquent and anti-social influences. For this reason, it is especially important that the goals of institutional placement are specified and evaluated carefully to avoid complacency in the care and treatment of passive-conforming young people.

This same pattern appears to hold true with regard to educational goals where measurable improvements in attitude, academic achievement and skill development have been demonstrated as possible and feasible practice attainments with this group of young people (Jesness et al. 1972). In one experimental study using carefully matched lesson plans, classroom environments, and teaching styles, passive-conforming youngsters outperformed all other types of students (Andre and Mahan 1972). Yet gains in behaviour and educational developments do not appear to be predictive of non-recidivism for this group of young people as a whole (Jesness et al. 1972; Palmer 1976; Warren 1983).

The outcome of efforts to treat the problem of delinquency for this group is mixed. Many passive-conforming young people commit more offences after certain patterns of care and treatment than they did beforehand, and more than other passive-conforming young people who had received no treatment at all (Warren 1983). While according to Palmer (1978) variations in treatment outcomes are almost certainly related to differences within this group of young people, Lukin (1981) found that passive conformists with high post-test scores on enthusiasm, measured by the Jesness Behavior Checklist (1971b), performed better after institutional release than those who remained depressed or unenthusiastic. This gives credence to a long-standing clinical impression that passive-conforming young people can overcome their basic pessimism about themselves and, as such, self-assertion is a worthwhile goal to pursue in practice with such young people.

The selection of care and treatment methods for this group of young people in institutional programmes appears to be of secondary importance, presumably once again related to their adaptability in the setting (Jesness i971a, 1975; Palmer 1972). In community settings where group care placements have been used as an adjunct to other therapeutic methods, the use of psychodrama (e.g. role play or “rehearsing” for job interviews), and family education approaches would seem to be preferable to family group therapy which emphasizes familial ownership of problems. Family therapy and Guided Group Interaction approaches (similar to practices found in a therapeutic community) seem to produce higher drop-out rates with the passive-conforming young people, presumably because of the heavy reliance in both approaches on the use of confrontation (Warren 1983). The use of an intensive, treatment-oriented approach with sound unit management and continuous feedback to both staff and young people would seem to be preferable to placement in a traditional, custodially oriented training school, youth treatment centre, or young offenders institution (Jesness 1980).

Even under favourable conditions, treatment successes with these youngsters would seem to be low. More disturbing is the realization that these youngsters seem to have low rates of recidivism while being supervised in certain community-based programmes. As long as they are closely supervised, it appears that these young people stay out of trouble (Warren 1983). Research findings such as these pose certain social policy questions about the care and treatment of passive-conforming young people. While placement in a residential setting which rigorously adheres to a treatment approach can make a difference, long-term supervision in the community would appear to have other benefits. Patterns of supervision using differential treatment methods can beneficially form networks around this type of youngster which can provide non-delinquent associations and create obstacles for criminal and delinquent influences. The problem associated with this option is that such methods of intervention do not seem reliably to achieve the goal of preparing passive-conforming young people for situations where they will need to resist criminal influences after supervision is withdrawn.

It may be that programmes involving volunteers and networks of community neighbours, teachers, and other resources in the “ecological” environment will find more success with this type of young person. Successes with this approach should be easy to determine, since flight or re-arrest is imminent for these young people when delinquent influences or fear prevail. For group care teams, these youngsters present a special challenge. Treatment success almost certainly involves helping them to overcome their pessimism about growing up and standing up for themselves. Care and treatment which seeks to increase these youngsters” interpersonal complexity and helps them internalize a set of personal values would seem to be realistic and worthwhile goals to pursue. Whatever the method, intervention should seek to involve the youngster as an enthusiastic ally in a carefully considered process of developmental learning.

Power-oriented young people
Subgrouping of young people described as middle maturity,

“This group is actually made up of two somewhat different kinds of individuals, who nevertheless, share several important features with one another. The first [cultural conformist] like to think of [themselves] as delinquent and tough. [They are ] more than willing to “go along” with others, or with a gang, in order to earn a certain degree of status and acceptance, and to later maintain [their] “reputation(s)”. The second type [antisocial manipulator or counteractive young person] ... often attempts to undermine or circumvent the efforts and directions of authority figures. Typically this second type of youngster will attempt to assume a leading “power role” for [themselves].” (Palmer 1974: 12)

The first type of power-oriented young person can be illustrated in the example of a boy who during an admissions interview stared “daggers” at the interviewer and answered questions in monosyllables, volunteering very little information. The young person's social and delinquency history, plus descriptions extracted from conversations where the lad was more willing to talk, revealed a picture of someone who had few experiences of a social world beyond his involvements with a very distinctive peer group. During a period of observation the lad was seen to “melt” into the institutional routine. As far as staff were concerned the youngster subtly took on roles of power and loyalty to peers. Clearly not a leader, the youth fell into the role of protector, extortionist, and “muscle man” with a subgroup of residents who were physically stronger and more street-wise than others in the centre. When staff moved in to reduce the influence this subgroup had in the living-unit, the boy in question assaulted a staff member from behind, using a weapon he had concealed in a unique and creative place, making it both handy and lethal. Research has shown that young people of this type commit significantly higher rates of violent offences as compared with any of the other delinquent sub-types (Warren 1983).

The second type of power-oriented youngster, the anti-social manipulator, has been described as being closest to the description of “psychopathic”, “sociopathic”, or even “character disordered” personality as found in other assessment typologies. The term “anti-social manipulator” has come under disfavour by many practitioners using this typology, thereby prompting a move from group care workers and others to change the term to refer to “the counter-active youngster”. This move is aimed at removing what is perceived as stigmatization associated with the label. This apart, there is no disagreement about the way these youngsters present themselves in practice.

One youth of this type described a situation leading up to his arrest with a friend, after the two “just happened” to go to the home of an acquaintance for a visit. During the visit, the friend pulled a knife on the host and this youth thought it had something to do with money owed to his friend. During the financial transaction, the counter-active youth decided he would listen to the stereo, turned it up to full volume and entertained himself by dancing in the room while the other two boys discussed the method and timing of repayment. Not long after he and his friend left the house, the two boys were arrested in front of the same house when the host pointed them out to the police. When asked why he and his friend had stayed in front of the house, the boy replied that they had not really stayed in front of the house. Since it was a nice evening, they had decided to walk around the block two or three times. The boys just happened to be passing the friend's house when they were arrested.

Research findings support the view that placement in residential group care using specific care and treatment approaches is the best option for some “power-oriented” young people (Jesness 1975; Warren 1983). Even placement in a traditional, custodially oriented training school appears to be a better choice than community-based treatment, including the use of different types of group homes (Palmer 1976; Warren 1983). While it would seem that substantial gains may be achieved in educational objectives, psychological growth, and behavioural management, such gains do not appear to be predictive of future job and school successes or non-recidivism (Andre and Mahan 1972; Jesness 1971a, 1972; Palmer 1976). Findings on treatment outcome with power-oriented young people would suggest that the selection of an appropriate care and treatment approach is a critical variable. Jesness (1975) found that counter-active young people responded better to treatment if they were in a programme which used transactional analysis as compared with those who were treated in a programme which used behaviour modification.

In sum, while it would appear that these youngsters respond better in circumstances where structures and controls are known and expected, and where sanctions are both timely and warranted in the eyes of the peer group, some of the power-oriented young people seem to benefit from alternative methods of treatment. A major problem in recommending care or treatment plans for this group, beyond the “minimum requirement” of justice, is that present measures of progress have not been shown to distinguish between young people who will be rearrested, reconvicted, and reincarcerated, and those who will not. In other words, no measures of progress are readily apparent upon which to base continuation or discontinuation of care and treatment approaches. Palmer (1974) found that all the middle-maturity groups, including the power-oriented type, tended to respond better to care and treatment efforts if the youngsters were admitted before the age of sixteen.

The implications arising from findings such as these are complex. It could be that positive results are to be attained through the use of time-limited periods of residential supervision in treatment-oriented group care centres. Such uses of residential supervision and control may, however, seem severe if sentencing guidelines do not take account of differential assessment and research findings. In short, two people committing similar crimes could receive different responses. This problem is reduced, in part, because cultural-conformists may self-select institutional placement with their assaultive offence histories. Obviously, assessment typologies cannot be used in isolation from other facts, or as the sole basis for institutional placement. However, the implication remains that when anti-social or delinquent behaviours begin, they tend to persist with all young people (Loeber 1982), but such persistence is particularly significant with the power-oriented young people (Warren 1983). Changes can be fostered with some of them but high structure appears to be necessary, if only to forestall patterns of re-offending or to provide a basis from which a care and treatment programme can operate.

Internally conflicted young people
In this group of higher maturity young people,

“We find two separate personality types which share certain important characteristics with one another. The first type [acting-out] often attempts to deny–to [themselves] and others–conscious feelings of inadequacy, rejection, or self-condemnation. Not infrequently, [they] do this by verbally attacking others and/or by the use of boisterous distractions plus a variety of “games”. The second type [anxious] often shows various symptoms of emotional disturbance – e.g. chronic or intense depression, or psychosomatic complaints. [Their] tensions and conscious fears usually result from conflicts produced by feelings of failure, inadequacy, or underlying guilt.” (Palmer 1974: 12)

The internally conflicted group accounts for the largest number of adolescents found in settings for delinquent young people (Warren 1983). This is also the group for which qualified treatment success can be reported. One girl, assessed as acting out, sat patiently through a meeting with her father who had come to visit her in a residential centre. After the father repeatedly told her “how hurt your mother is over this whole affair” and how “they still loved her”, the girl shrugged her shoulders and returned to her bedroom. Hours later she exploded. Within the space of a few minutes she wrecked her room, cut herself and smashed her best friend's Christmas gift. All the while she made obscene curses and shrieks of pain. Afterwards the girl said “Everything is OK now, I just want everyone to get off my back.” For this girl, acting out was a familiar way of achieving a measure of relief from her pain.

The anxious group of internally conflicted young people typically use introspection as a temporary, and ultimately self-defeating, relief from inner turbulence. One boy, who had just met a new staff member in a group home, sat up all night talking about the problems he had with his own parents. Encouraged by the boy saying he “felt better” after their talks, the counsellor repeated this activity for two more days. At the weekend, the boy became depressed for no apparent reason. Subsequently, it was discovered that the boy had interpreted this worker’s actions to mean that he thought the boy “needed” extra help. The boy had become immobilized through his personal style of “mindreading”.

Research has shown that internally conflicted young people can be successfully treated in carefully planned and evaluated programmes of care and treatment (Jesness 1975; Palmer 1974, 1976). Some important features of successful treatment approaches would seem to be:

A range of residential group care resources would seem to have played important roles in the successful treatment of internally conflicted young people. Different types of group home, shelters, and other short-term, back-up units and day resources have been used to achieve a variety of goals (Jesness et al. 1972, 1980; Palmer 1972, 1976). Summarizing the characteristics of different settings and types of group care resources which have contributed to success with internally conflicted young people is an extremely complex and perhaps dangerous task. For example, judging a treatment approach in one setting with one type of young person as successful may have little bearing on the same type of young person in a different type of setting. For this reason, only general clinical impressions will be given.

The use of personal contracts is generally supported. This seems to hold true for behavioural management (Jesness et al. 1972; Moos 1975), education (Andre and Mahan 1972); and type of treatment (Jesness 1980; Palmer 1976). The findings support the clinical view that internally conflicted young people can and should be involved as knowing partners in any care and treatment efforts. In short, staff must work to elicit the perspective and meaning which each of these young people places on the daily events in their lives. It is not possible to “merely supervise” internally conflicted young people. These young people must be engaged as individuals, consciously to support them in their use of psychological controls and their enactment of purposeful behaviour. This requirement for personal involvement may help to explain the unique patterns of frustration reported elsewhere in this volume for group care personnel working with internally conflicted young people.

So far, it would seem that success in the residential phase of care and treatment is more closely related to differences between the acting out and the anxious types of internally conflicted young people than to the selection of treatment methods. Jesness and his associates (1972) found similar success rates for all internally conflicted young people when comparing a programme which used transactional analysis with another one which used behaviour modification. Furthermore, both of these treatment-oriented options were found to offer better results than placement in a traditional, custodially oriented institutional setting (Jesness 1980). When Lukin (1981) accounted for pre- and post-test differences on the Jesness Behavior Checklist (1971b), she found that acting out youngsters were less prone to recidivism if they had improved on certain measures (e.g. friendliness and responsibility). For the anxious-conflicted group, Lukin found that success meant change in the opposite direction, that young people who performed better after release had shown a decrease in anger control and social control during their period of residence. Such findings could pose problems for any service which viewed a reduction in anger control or an increase in anti-social behaviour as evidence of failure. Other measures on the California Psychological Inventory support the idea that treatment progress can be documented amongst internally conflicted young people (Warren 1983).

Although specific academic and life skill achievements may be attained in residential and day care programmes, particularly in specialized classrooms, such achievements cannot be associated necessarily with future job and school successes, or reduced recidivism (Andre and Mahan 1972; Jesness et al. 1972; Palmer 1976; Warren 1983). While such findings do not come close to the definitive statement on care and treatment for internally conflicted young people, the findings do establish some key assumptions which are of importance to social planners, group care practitioners and others involved in work with youngsters such as these. First, some residential programmes committed to planned care and treatment may have an impact on the psychological conflicts which these young people have and thereby reduce their chances of recidivism at some time in the future. Second, such programmes need to be flexible enough to take into account the important differences between residents when administering and evaluating care and treatment activities. Third, group care programmes working with internally conflicted young people must be skilfully managed so that they work closely and co-operatively with other community services, as a part of a larger effort with these youngsters and their families.

While statements such as these may seem obvious to many practitioners, they have been challenged repeatedly in North America and Great Britain (Cornish and Clarke 1975; Lerman 1975; Lipton, Martinson, and Wilks 1975; Romig 1978). No summary of research findings from the California Youth Authority programmes has failed to comment on the accusation that the data generated by these programmes was “managed” (Robinson and Smith 1971). Others have more cautiously pointed to possible flaws in the research related to the ways in which many repeat offences may have gone unreported by treatment workers during the period of community supervision (Becker and Herman 1972; Lemlan 1975). Such criticisms continue to cloud the findings that four years after all formal contact had ceased, follow-up data favoured by large margins the internally conflicted young people who had received particular types of treatment (Warren 1983). In spite of the criticisms associated with the cost of treatment and the amount of social control involved (Lerman 1975) group care practice can ill afford to ignore the successful outcomes achieved through the use of differential care and treatment efforts with internally conflicted young people.

Presentation of the assessment

Of course, no assessment typology can provide more than a reference point from which to study and evaluate other assessment data. A differential assessment typology can be used to develop an interactional perspective in situations involving person-problem relationships. At the very least, assessments of this type should include:

  1. A summary description of the young person, home and family, community, and cultural ties, which incorporates information associated with social, legal, medical, educational, and psychological assessments.

  2. A summary statement of problems, needs, and wants, with elaboration as required to pinpoint their specific nature. In most cases there is no reason why such statements cannot be verified, or at least examined and evaluated by the young person's family throughout the early stages of treatment.

  3. A statement of goals and long-range issues which will be taken into account in working with the youngster.

  4. Identification and discussion of immediate issues or recommendations.

  5. Statement of risks, limitations and minimum expectations which will be maintained for the young person for a given period of time.

Assessments may involve a variety of personnel but the actual integration of the material into a set of working statements should be prepared by someone who has an overview, as well as a practical understanding of the care and treatment options available. Such a person(s) should understand differential assessment concepts and research issues sufficiently well as to be able to write behavioural objectives. This latter skill is vitally important since the assessment will need to be written and interpreted across a wide variety of group care practitioners. In instances where the assessment worker is enlisted to help define objectives, or to give specific consultation and advice for staff, the Offender Intervention Scales (Palmer 1978) may be of particular relevance. For example, a goal for one young person might be to increase his or her perception of the world and of themselves. However, workers may be presented with problems of apathy and indifference. The Offender Intervention Scales offer some possibilities for direction:

Still it remains for group care workers to translate such advice into their pattern of practice in a residential or day care centre. Maier s (1979) summary of research and comments about the rhythmicity between children and care-givers in nurturing, caring, and purposeful interaction are of particular relevance. The introduction of differential diagnostic and assessment information into group care centres can create tensions for teams of workers who want assessments to give prescriptions about what to do, rather than provide a framework, from which to consider a young person's behaviour within a total plan. It must be remembered that the onus of responsibility, for developing successful group care and treatment programmes, rests with the agency which provides the service. As such, the goals for an individual young person must be sufficiently broad as to embrace both residential and non-residential resources but practical enough to be meaningful for those working directly with a youngster. Much of the expertise needed to translate these goals into achievable objectives must come from the group care workers who manage and provide direct services in a chosen resource.

This is no small matter, as is evidenced in the following example of a sixteen-year-old boy whose behaviour in a residential centre led to heated discussion amongst staff about what each should be doing with the lad. Some felt that immediate behavioural sanctions should be imposed. Others said they had forestalled the need to do this by not reacting directly to the boy’s behaviour and by redirecting or diverting the boy’s attention. One staff member claimed that the boy was “challenging our authority” and another said that the boy was “just trying to be one of the group”. The assessment process revealed a boy who was so intemally conflicted that he took all interactions very personally. Staff agreed to view his behaviour as an anxious request for personal attention. The boy subsequently told his counsellor that he was “not sure who he was at times” and that he felt silly for acting the way he had when he was admitted. While any number of responses might be appropriate for some young people, this boy’s “make-up” would indicate that a carefully formulated care and treatment plan had special relevance for him.


Personal care and treatment plans are rendered uniquely difficult in group care settings by the powerful emotional involvement engendered by residential living. Feelings are known to touch on the beliefs and attitudes of all involved, and not just the group care workers, who have varying conceptions of “what youngsters need” and how these needs should be met. Research evidence obtained through the use of “matching” in education and other treatment settings (Hunt 1971; Palmer 1967, 1976) presents a powerful argument for differential assessment in group care and treatment settings. Brill (1978) demonstrated the utility of the Conceptual Level Matching Model in residential centres which assign a “primary worker” to do a variety of tasks with and for residents. This method (Reitsma-Street 1982) of matching worker and resident according to perceived need for structure in their social environment is comparatively easy to use and has found support from direct practitioners, managers, and researchers.

Others have found that even simple assessment distinctions between young people can provide valuable assistance to those engaged in group care practice: Agee (1979) “instrumental vs. expressive”; Dockar-Drysdale (1975) “integrated vs. nonintegrated”; Maier (1981) “go-go vs. living radars”. Teams will only integrate and use as many assessment distinctions as there are sound options available when it is felt their resource is not “best” or “good enough” for a particular resident. If teams operate on the assumption that their programme is best for all or even most youngsters, then such an attitude will cloud the development of particular areas of strength. While tensions can arise, it is also the case that differential assessment can be of immediate benefit to the selection of workers, a particular regime of activities, or even more specialized routines of care, education, and treatment. Group care teams require assessment information which is sufficiently complex as to enable them to achieve personal involvement with each youngster over time, but not information that is so complex that frustration will be generated about issues which are insoluble or not fully understood.

Finally, practitioners are left with the question of whether an assessment should attempt to provide information which is specific to a particular treatment method. For example, if a programme uses behaviour modification, transactional analysis, or perhaps even Goal Attainment Scaling (Bartelt and Colon 1982), should the assessment provide information on base-line behaviours, life script, and so forth? The answer is probably no, in most cases. Once again, it is important to remember that assessments cannot take the place of a clearly formulated personal care and treatment plan. The inclusion of behavioural objectives is recommended in most instances, and practitioners who aspire to do particular treatments must learn to write intervention objectives as an integral part of their care and treatment approach.


1. See Palmer 1978; Moos 1975; Fulcher and Ainsworth 1981 for guidelines on the preparation of programme descriptions.


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This chapter: Burford, G.E. (1985). Personal care and treatment planning. In Fulcher, L.C. and Ainsworth, F. (Eds.). Group Care Practice with Children. London and New York. Tavistock Publications. pp. 107-134.

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