by Laura Steckley
Laura Steckley is a lecturer in the School of Social Work and Social Policy at the University of Strathclyde. Her teaching interests within social work include residential child care and ethics . She is the course director for the MSc in Residential Child Care.
Care versus Treatment: Reflections on Residential Child Care in Scotland
In early January, 1999, I moved from the Western Slope of Colorado to Edinburgh, Scotland. I was 30 years old and had spent almost all of my post-university working life in residential treatment facilities for adolescents. While I had decided to change the location of my home, I was clear that I did not want to change the type of work that I did. I still wanted to work therapeutically with youth who were experiencing difficulties.
I was fortunate to land a job at a residential school for boys with emotional and behavioural difficulties a few months after the move, and in many ways, the work was the same. Yet it was also different – subtly different and, at the same time, radically different. This paradox was bewildering during those early years.
It seems fitting to offer some reflections about these similarities and differences to this special issue of the goodenoughcaring Journal. They are grounded in personal experiences and are thus anecdotal; I am neither making absolute claims about the state of residential treatment beyond my former places of work at that time, nor about residential care more generally here in Scotland. Nevertheless, I do think that some of my experiences will resonate with those of other practitioners and that my struggle for insight may offer some illumination.
I got my first bit of traction in making sense of the transatlantic differences in the differing names given to the work I was doing. Before I even started applying for jobs in Scotland, I was strongly advised to refer to my previous work experience as something other than treatment. I was told that people would misinterpret the use of that word as some sort of medical intervention. While I accepted the advice, it bugged me. Surely the work we were doing was more than just care.
As a result of my time in Scotland, I have come to understand care in a much less simplistic way. Through this process, I have come to see treatment differently too. Treatment (as we adults perceived it) was a safe but challenging haven for kids to come and tackle their problems. We had treatment models, behavioural targets, point-and-level systems. We tried to create environments and processes that promoted a stronger sense of personal responsibility, self-esteem and ability to manage out there in the ‘real world’. We wanted to be agents of change, working with kids to improve their lives. We believed in their abilities to change, heal and grow, and we had high aspirations for them. This was the case for most, but alas not all of us.
Residential care as I experienced it in Scotland was home-like, and indeed the quality of the physical environment was much higher than anywhere I had worked or visited in Colorado. To be fair, I had never worked in a group home in the States but they tended to be more poorly funded (or charged less per bed) and the accounts from kids and some colleagues were woeful. I was immediately impressed by the quality of decoration and furnishings of the residential school in Scotland and what this communicated about how kids were viewed. The staffing ratios were significantly different as well. I went from ratios of 18 to 2 and 28 to 5 (kids to adults) in Colorado, to a 10 to 5 in Scotland. There was more money in Scotland for activities and for transporting kids to their homes of origin at the weekend and even midweek. We had a cook through the week and a team of domestic staff who not only kept the place clean and tidy, but did things like pressing the sheets. I remember initially thinking that so much more was possible with the level of resources we had.
I knew I had to acclimate to a new culture. I didn’t want to be a know-it-all American, but I did want to bring my own relevant knowledge and experience to the mix. It was hard to figure out what, from my previous work, was applicable and what I needed to discard. One of my first realisations was that people thought very differently here in Scotland about what we were doing and why we were doing it. There were no treatment models, no explicit behavioural targets and no point and level system. I had already begun to entertain doubts about the latter, but the lack of clear articulation and referable sources of theory to inform our efforts to help these boys became a source of frustration.
Now I’m not claiming that there was an especially high level of congruence in terms of shared understanding and practice in my places of work in Colorado; indeed, it was often inadequate. However, it felt light-years ahead of where we were in Scotland. When I would try to discuss a theoretical perspective or would encourage colleagues to read about something we were experiencing at work in Scotland, it frequently became awkward. People seemed to pull down the shutters. I’m pretty sure that sometimes I was coming up against a seam of anti-intellectualism that runs through not just Scotland, but the United Kingdom. The inherent distrust or dismissal of theory was palpable at times, and my enthusiastic, irrepressible and often irritating desire to understand was probably like nails on a chalkboard to some people’s deeply pragmatic ears. Even the intonation given to the word ‘theory’ made it sound fluffy, irrelevant or merely like an opinion.
I must stress that I did not experience all of my colleagues this way in those early days, and during my fifteen years here in Scotland I have encountered many deep thinking, theoretically committed and critically engaged members of our sector. That they are not the norm is clearly related to the legacy in Scotland of no required qualification for working in residential child care. Just four days ago, the Minister for Children and Young People, Aileen Campbell, announced the Scottish Government’s commitment to a degree level qualification becoming the standard for residential child care workers, supervisors and managers in Scotland. This is hopeful news. It is also threatening news to many, and rightly so. Bringing the workforce to degree level will require significant resources, and it is unclear where these resources will come from. There are workers who are good with kids but not with reading and writing. We may lose them. If the curriculum doesn’t actually equip practitioners with the skills, knowledge and capacities needed to meet the needs of our kids, it will be a catastrophic waste. Equally worrying, if the necessary investment in making this project work is not forthcoming, Scotland will have taken a deeply cynical turn.
In 2001, I had the good fortune to be included in the first cohort on the MSc in Advanced Residential Child Care at the University of Strathclyde. The then Scottish Executive established the Scottish Institute of Residential Child Care (located in the University of Strathclyde) to develop the education and training of residential child care workers, and the MSc was part of this initiative. It should be said that there was no such commitment to the education of residential child care workers in Colorado, and I don’t think there has been anything that comes close to Scotland’s investment anywhere in the wider United States.
It was through my studies and exposure to other practitioners that I began to understand better some of the other differences between care and treatment. I would characterise one of these differences as a macro-orientation versus a micro-orientation. In trying to make sense of this, I recently wrote the following:
As an American, I brought my ‘can do’ attitude to my practice in Scotland and was sometimes shocked at the apparently low expectations and aspirations my colleagues seemed to hold for our residents. Over time and with the aid of my studies on the MSc in Advanced Residential Child Care, I developed a far greater appreciation of the impact of elements of the macro-system … on the development and life-chances of children and young people. I came to understand that my Scottish colleagues also had this greater, albeit often tacit, appreciation than I (or my American counterparts) had had. The more I (re-)engaged with knowledge about elements of these macro-systems and their impacts, the less I felt able to be that positive change agent. Paradoxically, I began to wonder whether our American ignorance of one level enabled stronger, though inadequately-informed, optimism and enthusiasm on another. In Scotland, I much more frequently felt a collective sense of pessimism, or at least withering, as we approached our work. This was compounded by the aforementioned lack of therapeutic orientation to residential child care in Scotland. Yet it was not possible or desirable to go back to that former ignorance. Focus on the micro to the exclusion of the macro is problematic; the opposite is true as well.
Looking back, I can’t help but wonder whether sometimes my colleagues’ shutters came down because all I was talking about in those early days was focused on the young person and his family. The impact of poverty, disadvantage, stigma and social exclusion rarely if ever were topics of discussion in Colorado (or in my early days in Scotland). Not only did our treatment models pathologies kids, placing an inordinate focus on problems and deficits, they were implemented with an inherent blame of families and blindness to their social conditions. We spoke to kids of making choices in such simplistic, unintelligent ways: ‘You can make better choices.’ No wonder they responded with ‘Fuck off’.
An appreciation for the often grim social circumstances of families whose children end up in residential care sometimes comes at a cost, however. I recently heard this cost referred to as ‘The soft bigotry of low expectations’. What a compelling form of words. After a short search I have come to find that this compelling phrase has been used by political figures who consistently dismiss or avoid the very real impacts of poverty, disadvantage, stigma and social exclusion. What does that tell us? I think it highlights how difficult it is to hold the big picture and the small picture in mind at the same time. It’s hard enough not to shield ourselves from the pain and despair our young people bring to the therapeutic encounter; how are we meant also to be present with the pain and despair that comes with really seeing the entrenched social structures that perpetuate poverty, disadvantage, stigma and social exclusion?
The answer is care. Good care. My irritation at being told to refer to the work I had done in Colorado as care was rooted in a superficial and simplistic understanding of the word. I have come to understand that care is actually more complex and demanding than treatment. The roots of development and recovery are in the rich soil of good care experiences. A care perspective is more holistic and requires a more robust involvement of the self. Fundamentally, care is about meeting the needs of the other; if these needs are complex and require advanced skills, knowledge and capabilities, then good care means developing those skills, knowledge and capabilities. And over the last decade and a half, I have witnessed a growing consensus that residential child care is complex and requires advanced skills, knowledge and capabilities.
Care has also become a significant focus in analysing entrenchment of poverty, disadvantage, stigma and social exclusion, as noted above. As I’ve discussed elsewhere, the positioning of care as private, feminine, individual and peripheral to the central concerns of society keep the vast majority of those who give direct care in the least powerful positions in society. There are growing numbers from a variety of disciplines who are beginning to challenge the way care is thought about and how it serves to preserve inequalities of power and privilege. They are moving care from the periphery to the centre of human and political concern. Thus what we have here is a melding of the macro and the micro – the big picture and the individual encounters within it – in a more profound way than treatment can offer. Care is giving us a way to discover how to hold the individual, intimate connection and healing while also holding and taking to task elements of that bigger picture.
To return to the paradox about care and treatment: In coming to Scotland, I quickly discovered a concerning lack of theorising and pockets of anti-intellectualism in the work. However, over the years I have witnessed Scotland’s deeper understanding of and commitment to care. It is a better way forward.
Jeremy Miller writes,
Really enjoyed your reflective piece. It articulates the dilemma I have lived with all my days. I know that things could be better for all our children given the political will. We have the evidence base to prove that reducing inequalities is the single most powerful agent for change from the top to the bottom of society. We cannot ignore this knowledge and we must speak truth to power at all times.
At the same time we must not use the experience of wilful political inaction and oppressive action to dull our humanity and make us less compassionate. We cannot be drawn into this neo-liberal race to the bottom. I do this by investing in relationships and committing random acts of kindness. I have tried to do this throughout my career with little regard for the structures of power. We all have this power at the micro level to create dissonance in the minds of the apparatchiks of the system.
The possible shiny new Scotland brings truth democratically closer to power and that will result in a boost for compassion and caring. The micro merging with the macro.