Therapeutic residential care services in Australia
Who completed the survey
Partial responses were received from 192 respondents. A visual inspection of this data indicated that incomplete responses were provided by frontline workers, who did not complete questions related to funding, staffing configurations or theoretical approaches. It was not possible to determine a response rate for this survey as the number of surveys distributed was not recorded.
Completed surveys were received from 31 participants, and a further six surveys met the '75% complete' criterion; yielding a total sample of 37 surveys. The completed surveys represented the views of 26 separate agencies and included responses from all Australian jurisdictions. There were insufficient data for each jurisdiction to allow cross-jurisdiction comparison; therefore, data from all jurisdictions were pooled for subsequent analysis. The distribution of participants across jurisdictions is reported in Table 1.
|Jurisdiction||No. of participating services|
Participants were asked to identify their organisation; and their role within the agency they were reporting on. The majority of participating services identified as non-government service providers (91.8%; n = 34); and three identified as government providers of therapeutic residential care. The majority of respondents (n = 32) were in leadership roles; with only five frontline workers completing the survey. Table 2 presents participants' respective roles within the agencies they represented.
|Role||No. of survey participants|
Note: * = includes government and non-government respondents; ** = includes child safe leads and practice leads.
Each participating organisation was asked to estimate how many young people in total were cared for by their organisation. The estimate for each agency was combined to provide a rough estimate of the total number of young people whose needs were being reported on in this survey. Collectively, the 37 respondents in this study estimated that they were caring for approximately 1,236 young people.
If accurate, this number reflects a significant portion of the current residential care population. Nationally, approximately 2,396 (or 5%) of the 47,915 children in out-of-home care live in residential care (Australian Institute of Health and Welfare [AIHW], 2018). This suggests that the data collected may reflect the current care circumstances of a significant proportion of young people currently living in residential care. Indeed, the estimate provided by participants suggests that the services that took part in this survey may collectively be caring for around half of young people who currently live in Australian residential care. Unfortunately, it is unclear what proportion of the total number of existing Australian residential care services are represented in this survey because at present Australia-wide information on the total number of residential care services in Australia is not collected or reported.
Overview of therapeutic residential care
The survey questions covered three main areas of interest that aimed to provide an overview of Australian therapeutic residential care services. The fourth area covered by the survey related to participants' views about therapeutic residential care as it is currently configured, together with their recommendations for further developing this form of service delivery. Taken as a whole, the findings of this survey are designed to provide a snapshot of current practice in Australian therapeutic residential care, in relation to:
- service and staffing characteristics
- the care needs of young people being supported
- therapeutic frameworks, models and practices, and staff/program activities
- key issues informing future development in the sector.
Each of these service characteristics and related issues is described in the following sections of this report.
Participants were asked for information about how their service was funded and what kind of funding they received. Participants also provided information about the physical characteristics of their residential group homes: where these were located, how many residential homes their service had and of what size. Participants were given the opportunity to describe their staffing configuration and the qualifications and other characteristics of their workforce. In addition, they were asked to describe the strategies they used to support workforce retention. These characteristics of the care environment have been identified as key considerations for the delivery of therapeutic residential care (e.g. Boel-Studt & Tobia, 2016; McLean, 2018).
Funding for services
Participating services were asked about their funding type and source. Internationally, residential care services can receive referrals through youth justice and child mental health services, which may be funded by a variety of sources. In Australia, therapeutic residential care is predominantly within the statutory child protection sector, and funding is typically provided by the relevant state or territory government. The way that services are funded can influence diverse and nuanced aspects of the resultant care environment; including the configuration of staffing, the nature of the workforce, the capacity to offer longer-term contracts, and the degree to which services can influence their referrals and placements. For these reasons, it is important to better understand the way Australian services are funded.
While all participants identified themselves as providers of therapeutic residential care (n = 37), not all services were funded accordingly. Services were asked whether or not they were funded to provide therapeutic care, with 31 services responding. Around a fifth of these indicated that they were not actually funded to provide therapeutic care (n = 8; 21% of total sample). This suggests that some services may be attempting to accommodate young people's needs within a general residential care funding model.
Services were asked about the sources of their funding. In order to answer this question participants were asked to select a response that best described their source of funding from a list of options. Thirty-six services provided a response to this question. Thirty-four services were able to identify a funding source, and two participants reported that they were 'unsure'.
Most services reported that they were funded through block funding (n = 14), and recurring government grants (n = 6). These are forms of funding that offer services a specified funding amount and for a defined period of time, typically with allowance for establishment costs, providing a measure of certainty and predictability for services that can enhance staff recruitment and retention. The next biggest group of services were those funded through a combination of block funding and individual funding (including individual funding packages or fee for service Child Related Costs Placement and Support Services (CRC PaSP) (n = 6). Five services reported being funded only by individual funding packages or CRC PaSP funding. Tailored financial packages such as these are typically provided in recognition of the additional complexity and support needs of some young people for whom they are allocated. A minority of services were funded via individual flat fee funding or a yearly estimate package (n = 2) based on an individual child's needs. One service received funding through an affiliated religious organisation.
Number and location of homes
Participating services were asked about how many therapeutic homes they ran; and about the size and location of these services. The size and location of residential care homes has been the subject of much debate in the international literature. Some argue that small 'home-like' environments situated in the community are ideal as they offer a normalised environment for young people and avoid the possibility of group contagion; while others argue that larger homes, or clustered home arrangements, afford an 'economy of scale' that can support the cost of highly qualified, multidisciplinary teams (see Ainsworth & Hansen, 2015; Ainsworth & Hansen, 2018; McLean, 2018).
Number of homes
There was wide variety in the number of therapeutic homes being run by each service. Across Australia, the number of homes provided by each service varied between one and 60. The median number of homes was 5-6 homes; but there were also a few services that were providing support to a larger number of homes. The modal (most common) number of homes provided by each service was two therapeutic homes.
Size of homes
There was less variation in the size of therapeutic homes across participating services. The median number of places for young people in each home was four. Four-bed homes were also the most common (modal) placement configuration across Australia. Across the group, the size of homes varied from one-bed homes to a much larger home that reported providing care to 16 young people at one site.
Location of homes
Services were asked about whether their homes were located in metropolitan, regional or rural locations. Thirty-six services provided information about the location of their residential homes. Of these, 26 indicated that they had homes in metropolitan areas, 25 had homes in regional areas and nine had homes in rural areas. Most services were providing some mix of metropolitan, regional and rural homes. Most homes were in metropolitan locations (the largest metropolitan service had 17 homes); and the median number of homes in metropolitan locations was three. The median number of homes in regional locations was also three. The largest number of rurally located homes was three. In open-ended responses, one service provider commented that they also had homes in remote locations; however, this information wasn't able to be quantified in the current study.
Physical characteristics of homes
Internationally, residential group homes can be offered in small suburban homes, in small clusters of homes grouped together, or in larger residential facilities. Service providers were asked to select which of these options best described the configuration of their homes. Thirty-seven services provided information about the physical characteristics of their residential homes. The majority of services (n = 30) identified that they delivered therapeutic care in small suburban homes located in the community. Five services reported that they co-located their residential homes in small cluster sites; typically as a collection of smaller homes or units with one home allocated to staff. Four services reported using larger freestanding facilities.
This indicates that although small community homes are the most common type of therapeutic residential care homes, most services used a combination of housing styles to meet young people's needs, service requirements, and the practical constraints of service delivery. For example, many services are funded to provide four-bed homes, as this appears to be the accepted model for 'home-like' therapeutic service provision. Close co-location of homes may help services with the pragmatic concerns of providing supervision and support for a number of homes simultaneously, while providing young people with sufficient opportunity to develop independent living skills.
Participating services were asked to describe how their services were staffed and how staff were trained and supported. It is widely acknowledged that the quality of the relationship between young people and staff is an important element in effective and therapeutic care (e.g. Holden et al., 2010; Verso Consulting, 2011). The attraction, support and retention of appropriate residential care staff is a critical ingredient for the delivery of high quality, evidence-informed care (Boel-Studt & Tobia, 2016; Bravo, del Valle, & Santos, 2014; Grietens, 2014; Holden et al., 2010; Lyons & Schmidt, 2014).
Participants were asked to indicate whether or not their direct-care staff were required to hold a minimum level of qualification. All participants provided a response to this question. The majority of respondents (n = 26) indicated that they do apply a minimum qualification criterion. Nine services did not have formal specifications in place regarding qualifications of staff. Where further information was provided about the pre-requisite qualifications, the most common pre-requisite qualification sought by services was a Certificate IV in Child Youth and Family Intervention or similar (e.g. Community Services or Youth Work). Less commonly, services specified degree-level qualifications in psychology or social work, in combination with experience. This was more likely for clinical or therapeutic specialist positions, where a postgraduate qualification is desirable.
All services indicated that they use a rostered staffing model and provided details about this. Most services used '8-hour shift' rostering (n = 17); with the second most common rostering arrangement being '24-hour shift' arrangements (n = 10). Other arrangements included a combination of shifts, depending on days worked (e.g. three 8-hour shifts on weekdays and two 12-hour shifts on weekends; or rotating 12-hour shifts). The majority of services used active rostering for overnight staff (n = 21); followed by passive rostering (n = 12). Active overnight rostering means that there is always a staff member awake during the night to attend to young people's needs. Passive overnight rostering means the rostered staff member sleeps on site in the home with the young people. The remainder of responding services specified that they used 'other' rostering arrangements for night staff (n = 4); typically, an approved 'sleepover' arrangement in conjunction with an approved safety plan.
Services were also asked to describe their staffing ratios and to indicate whether or not there was a formally specified ratio of staff to young people for their agency. In response, 18 services indicated that a formal policy was in place for this; 16 indicated that they did not have formal specifications for staffing; and three were unsure. Of the 18 services that indicated that a ratio was formally specified, the most common staffing ratios were two staff : four young people (n = 9) or one staff : two young people in smaller homes (n = 5).
The decision about staffing ratios often was determined by funding bodies or, in some cases, by an assessment of young people's needs. Staffing ratios were typically reduced overnight. Where an overnight staffing ratio was reported, the most common overnight staffing ratio was one staff : four young people. Where no formal staffing ratio was specified, services reported that they nonetheless aimed for comparable staffing ratios; although many were providing higher staffing ratios (e.g. up to one staff : two young people or one staff : three young people) in many instances.
As a whole, this indicates that staffing ratios are generally quite high and many agencies are employing higher staffing ratios than would be suggested by their organisations' formal policy. This may reflect the emphasis placed on the relationship between workers and young people in a therapeutic approach. Alternatively, for some agencies, it may also reflect the need to provide care for young people with extreme behavioural and mental health support needs that require high levels of supervision.
Services were asked what, if any, initiatives they employed to support staff and reduce staff turnover. Thirty services provided responses to this question. Of these, 27 reported initiatives that were aimed to increase staff morale, wellbeing, professionalism or support; and three services weren't able to identify any strategies that they currently used to address these issues. Responses to this question were sorted and reported according to themes. Many agencies used multiple strategies. Some of the staff retention strategies reported by participants included:
Clear therapeutic model and practice leadership: promoting consistent and effective responses; promoting professionalism in the role; using 'key worker' roles; 'leading not managing' staff; and providing cultural support and related workforce development.
Rostering: using shortened rosters for high-intensity clients; offering flexibility in rostering to support work-life balance; using permanent rostering lines, modified where necessary to manage workload; rotating staff to other programs when necessary; specifying maximum percentage of shifts in any one house; using family-friendly rostering when possible; and making rosters as predictable as possible.
Emotional and collegial support: engaging therapeutic specialists to support staff; privileging relationships and creating a supportive environment; debriefing and prioritising a positive team culture and staff communication; having staff recognition events; providing 'fitness passports' to local gyms; providing staff wellbeing and reflective practice programs; providing access to EAP, chaplaincy and professional debriefing sessions; and ensuring staff access to cultural/ceremonial leave entitlements.
Financial stability: providing salary packaging and a pro-rata training budget; providing appropriate remuneration; offering permanent full- and part-time roles wherever possible; providing a supervision focus on career planning; and providing access to further training, development and study leave.
Professionalism: creating role autonomy and the ability to contribute to the ongoing development of programs; including staff in operational decisions; providing fortnightly reflective space sessions; providing practice-focused coaching; and using reflective logs, supportive supervision and practice reflection.
1. Service and staffing characteristics
- Most of the therapeutic residential care services surveyed are currently funded by block funding.
- Approximately one-fifth of services reported providing therapeutic residential care without explicit funding to do so.
- Four-bed therapeutic homes were the most commonly reported form of residential care homes.
- Small metropolitan homes located in the community were the most commonly reported type of therapeutic homes.
- The majority of therapeutic residential care services employed a range of initiatives aimed to increase staff morale, wellbeing, professionalism and support.
Participating services were asked about care arrangements, therapeutic service goals, and the characteristics and therapeutic needs of young people in their service. This information is important as it helps to articulate the goals of service provision for young people, and the supports needed to achieve these goals. This includes consideration of the therapeutic needs of young people, the staff skills, therapeutic activities and other elements needed to support young people effectively, according to their needs (Knorth, Harder, Zanberg, & Kendrick, 2008; McLean, 2018).
Young people's care arrangements
Services were asked to indicate the care status of young people accessing their service. Participants were given five possible choices of care arrangements and were asked to rank the most common care arrangements for the young people in their services. Thirty-five participants provided a response to this question. The common care arrangements for this group of services (listed here from most common to least common, according to group-ranked responses) were:
- guardianships to age 18 orders
- temporary/assessment orders
- mixed care arrangements
- voluntary care orders
- other person guardianship.
When given the opportunity to provide additional comments, 12 participants indicated that other care arrangements such as family reunification/restoration, shorter-term care and/or interim accommodation orders were also common forms of care for this group of young people. This highlights the need to document and track these outcomes; and suggests the need to include these categories in future research about the placement needs of young people in therapeutic residential care.
Therapeutic goals of service
Services were asked to provide an indication of the main goal of the service by ranking agreement with options from a list of possible service goals. Thirty-three participants provided rankings for this question. As a group, participants indicated that their service aimed to support young people with the following goals (listed here from most common to least common, according to group-ranked responses):
- recovery from trauma
- transitioning to independent living
- providing a permanent home until age 18
- daily care/containment
- re-connection with family
- re-connection with education
- needed placement following foster placement breakdown
- emergency care
- short-term care; with aim to reunify with family
- short-term care; with aim to place in foster home.
As a group of services, the least common goals involved 'intensive mental health treatment', followed by the 'supportive placement of family group', and finally 'transitioning from secure care (e.g. bail housing)'. In open-ended responses, 18 participants emphasised the importance of addressing young people's criminal behaviour; stabilising young people's social and behavioural functioning; supporting cultural connection; and building young people's emotional regulation and relationship skills, suggesting the importance of developing service responses to these issues as well.
Young people's characteristics and primary support needs
Participants were asked to select from a range of 10 broad categories that best described their client groups' main characteristics and support needs. Thirty-three participants responded to this question. As a group, participants indicated that their service addressed the following support needs (listed here from most common to least common, according to group-ranked responses):
- high risk/offending
- Aboriginal/Torres Strait Islander
- intellectual disability
- sibling group
- children under 12.
Although clearly these categories can overlap, they provide some indication of the characteristics and main support needs of young people in residential care. In terms of sex groupings, mixed client groups were the most common client groupings; followed by male-only groups and, less commonly, female-only groups.
Key therapeutic issues
Respondents were also provided the opportunity to comment on the key therapeutic issues for young people in their care. Eighteen services provided a response to this open-ended question. Common therapeutic issues identified by participants include complex clinical support and health needs such as autism, intellectual disability, complex trauma, mental health needs, challenging behaviours, sexualised behaviours and risk of sexual exploitation. Young people were also considered by respondents to be a heightened risk due to alcohol and substance misuse; lack of supports and family and cultural connection; offending behaviour; disconnection from education; and risk of homelessness.
2. The care needs of young people being supported
- 'Guardianships to age 18' was the most commonly reported care arrangement for young people living in therapeutic residential care.
- The most common therapeutic aims involved supporting young people's recovery from trauma and developing independent living skills.
- Therapeutic residential care appears to be common for young people with high risk or offending behaviour, for Aboriginal young people, and young people with an intellectual disability, among other needs.
- Complex clinical and mental health support needs, challenging behaviours and risk of harm were among the key therapeutic issues identified by participants.
Participants were asked to provide information about the therapeutic frameworks, therapeutic models and crisis-response models that guide their therapeutic practice; and about the staff-led practices and program activities through which these approaches are enacted. It is important to document the organisational frameworks and models that inform therapeutic residential care, as having a clear conceptual framework for workers' practice has repeatedly been identified as an important element of effective residential care internationally (Holden et al., 2010; Knorth et al., 2008; McDonald & Millen, 2012).
Therapeutic frameworks, models and practices
An important aim of this survey was to capture the main theoretical approaches and practices guiding therapeutic practice in the Australian residential care sector. The literature does not clearly distinguish between practices, model and frameworks; leading to the possibility that these constructs are confounded in discussions regarding effective therapeutic care. In order to support a clear distinction between frameworks, models and practices, the following definitions were provided by the author; these were developed in collaboration with the National Therapeutic Residential Care Alliance reference group for this project:
- Therapeutic framework: A therapeutic framework guides staff recruitment, policies, procedures and understanding of a young person's behaviour and needs.
- Therapeutic model: A therapeutic model guides daily interaction with young people, provides an understanding of their specific needs and shapes activity planning.
- Crisis intervention model: A crisis intervention model is what staff draw on when responding to escalating behavioural responses or reactive aggression.
Services were asked which therapeutic framework best reflects their service. This question was prefaced by the definition of 'therapeutic framework' provided above. Thirty-four services provided a response to this question; with 30 choosing a model from among the available response options. The majority of services (n = 22) identified 'trauma-informed care' as their guiding therapeutic framework, followed by the CARE framework (n = 4), then Sanctuary (n = 3), and finally Hope and Healing (n = 1).
Participants that did not endorse any of the available response options (n = 4), provided further detail that indicated their service had developed a therapeutic framework that was not captured by the response options provided. Agencies that had developed their own therapeutic frameworks described these as drawing on the principles of attachment-based and trauma-informed approaches; or as using elements of evidence-informed models such as Sanctuary and CARE augmented by various practices such as needs-based assessment, positive behaviour support and restorative practice.
Services were asked which therapeutic model best reflects their service. This question was prefaced by the definition of 'therapeutic model' provided above. Thirty-five services provided a response to this item. The majority of services indicated that they used an attachment model (n = 12); followed by a developmental model (n = 5); then a teaching family model (n = 2); and, finally, social learning, positive peer culture and behavioural/token economy models equally (n = 1 each).
In addition, a number of services indicated they draw on a therapeutic model outside of the choices provided in the survey (n = 11). Qualitative responses indicated that these services did not prescribe to commercially available models of care but instead had developed their own models for proactively addressing young people's needs, based on evidence-informed principles. For example, several services reported using multi-dimensional and needs-based developmental and biopsychosocial models, and models for creating supportive environments and skills development. Models based on principles of neuro-sequential programming, polyvagal theory and PACE were also reported.
In giving their responses, participants differentiated between these therapeutically focused models and models they drew on for responding to safety concerns, which focused on de-escalation and crisis responses (i.e. crisis intervention models, as reported next).
Crisis intervention model
Services were also asked whether or not they had a formalised model for crisis management. This question was prefaced by the definition of 'crisis intervention model' provided above. Thirty-five services provided a response to this item. The majority of responding services (n = 30) indicated that they do have a formal crisis management model that they draw on; however, there were also some services (n = 5) that indicated they did not have a formal model of crisis de-escalation and safety.
Services were asked to provide further details about the crisis intervention model they employed. Twenty-six services provided further detail about the model they used. The majority of these services were using the Therapeutic Crisis Intervention model from Cornell University (TCI) (n = 22); this was followed by Non Violent Crisis Intervention (NVCI); either used in isolation as the sole crisis intervention approach (n = 1), or as a supplement to non-aversive reactive strategies informed by individualised positive behaviour approaches (n = 3) (see Box 1).
Box 1: Crisis intervention and positive behavioural support in residential care
Get more information on the Therapeutic Crisis Intervention model.
Get more information on Non Violent Crisis Intervention.
For more information on non-aversive reactive strategies and positive behaviour approaches see:
- Crates, N., & Spicer, M. (2016). Reactive strategies within a positive behavioural support framework for reducing the episodic severity of aggression. International Journal of Positive Behavioural Support, 6(1), 24-34.
- Weiss, N., & Knoster, T. (2008). It may be non aversive, but is it a positive approach? Relevant questions to ask throughout the process of behavioral assessment and intervention. Journal of Positive Behavior Interventions, 10(1), 72-78.
Staff-led and program activities
Services were asked to describe the staff-led activities and program activities that were used in their services. Participants chose from a list of response options, and response scores were weighted according to group ranking. The need to better understand the kinds of activities that take place in therapeutic residential care services has been repeatedly emphasised in the literature (Axford et al., 2005; Knorth et al., 2008; McLean, 2018). The following definitions were provided to participants in order to provide guidance and consistency in responding to this question:
- Staff-led activities: Staff activities are the staff-initiated activities and programs that are intended to support young people's development.
- Program activities: The main activities that young people take part in as part of your program that are directed towards meeting their needs.
Participants were provided with the definition of 'staff-led activities' as described above, and asked to select from a list of seven staff-led activities. Thirty services provided responses to this question. As a group, participants indicated that their service commonly used the following staff-led activities (listed here from most common to least common, according to group ranking):
- educational/vocational programming
- living skills training
- recreational programming
- sensory activities/programming
- resident meetings
- family therapy/family connection
- sporting activities/training.
Participants were also given the opportunity to provide more detail through open-ended responses to this question. Thirteen services provided additional information. The main activity participants noted that was not on the existing list of response options was support for cultural connection, indicating this forms a large part of therapeutic residential care staff's role; and that it is an activity that is seen as distinct from family connection activities. Additional staff-led activities listed by participants revolved around building relationships, predictability and emotional safety using therapeutic parenting and social learning activities (i.e. where staff support positive relationships through modelling and opportunistic reparative learning experiences).
Services were also provided with the definition of 'program activities' as described above, and asked about the main program activities that are undertaken in order to meet young people's needs. Participants were asked to select common activities from a list of nine options. Twenty-nine participants provided responses to this question.
As a group, participants indicated the activities that were undertaken to meet young people's needs (listed here from most common to least common, according to group ranking - note some responses received equal ranking):
- Learning independent living skills
- Educational/vocational programming
- Cultural activities
- Mentoring; and Sporting activities
- Community volunteering
- Part-time work
- Group education sessions; and Tutoring.
Participants were able to provide additional detail in an open-ended response. Five services provided additional information, indicating that regular family access and family inclusion activities, regular health checks, psycho-education about self-regulation and self-care activities, and gardening were also program activities used to meet young people's needs.
3. Therapeutic frameworks, models and practices, and staff/program activities
- The majority of services included identified 'trauma-informed' care as their therapeutic framework; although the related CARE and Sanctuary therapeutic frameworks were also reported as influential.
- Most therapeutic services identified that their practice and daily interactions were guided by attachment theory, developmental theory and social learning models.
- The vast majority of therapeutic residential care services used a clear crisis intervention model, with Therapeutic Crisis Intervention being the most commonly employed model for enhancing safety.
- The focus of staff-led activities was commonly on the provision of educational and vocational skills, life skills and recreational programming. Cultural connection was named as an important staff-led activity.
- The focus of daily programming was similar - addressing young people's need for independent living skills, educational and vocational programming, and cultural connection were central to programming activities for therapeutic services.
The need to better understand and share knowledge about effective therapeutic care and the extent to which services are matched to need has long been acknowledged (James, 2014; McNamara, 2014; Whittaker et al., 2016). This can be summarised as a shift in thinking away from a 'one-size fits all' approach to service provision and towards an understanding of 'what works for whom, and when'. For this reason, it is important to learn from experienced service providers about what they think works well, and what needs to change, to further develop the effectiveness of this cost-intensive form of service provision.
Accordingly, service providers were given the opportunity to provide commentary in response to three broad questions:
- Which young people benefit the most from therapeutic residential care?
- Which young people are not suited to therapeutic residential care as it is currently designed and funded; and what changes could make it more effective for these young people?
- How might therapeutic residential care be improved to better accommodate the needs of young people?
Results of open-ended responses were grouped by content themes and are presented below.
1. Which young people benefit the most from therapeutic residential care?
Twenty-seven respondents provided commentary on this question. Some respondents expressed the view that therapeutic residential care is potentially beneficial to all young people, provided staff worked therapeutically; suggesting it is the practice, not the young people's needs, that makes therapeutic care effective. Other responses centred more on the characteristics of the young people being placed in therapeutic residential care. These comments centred on the age, relationship needs, motivations and engagement of young people. Within the commentary on these broad factors, there was considerable diversity of views. Commentary themes are summarised as:
Young people's needs as a consideration
Responses in this category discussed the potential for therapeutic practice to help all young people. Open-ended responses indicated that therapeutic practice is likely to be helpful for young people who:
- have experienced trauma, have complex behaviours, or who need intensive therapeutic support and stabilisation
- have experienced placement breakdown or removal and can remain in, and tolerate, therapeutic placement long enough to build healthy attachments to staff and prepare for another type of family-based care
- need high levels of supervision because of behavioural complexity or disability and/or are, therefore, unable to keep themselves safe.
Young people's age as a consideration
Views on how young people's age affected their suitability for therapeutic residential care were polarised. Some respondents felt that younger children were less disengaged from community, were less resistant, derived more benefit from a residential program; and workers felt more hopeful working with younger children as a result. Others felt that therapeutic residential care was a service of last resort that should work with older children; or that adolescents who require support and accommodation, who want more independence and don't want to be placed with a family were more suited to therapeutic residential care.
Capacity for relationship
Respondents also felt that a young person's capacity for relationship was an important factor in determining suitability for therapeutic residential care. On the whole, 'relationship' was seen as a shared responsibility; with both child- and staff-related factors seen as important. Staff capacity for providing consistency, warm relationships, safe and firm boundaries, and attuned care were commented on. At the same time, young people needed to be able to 'engage in a relationship' with significant adults in order to benefit from therapeutic residential care.
Capacity to engage
Respondents commented that young people who are engaged in some kind of learning or educational program were likely to be successful in therapeutic residential care. Engagement in these programs was seen by respondents as a marker of young people's motivation and 'future focus'. Drug use and criminal behaviour were viewed by respondents as indicators that a young person was disengaged and would be less suited to therapeutic residential care.
2. Which young people are not suited to therapeutic residential care as it is currently designed and funded; and what changes could make it more effective for these young people?
Twenty-four respondents answered this question. As previously noted, some respondents felt that all young people were potentially suitable for therapeutic residential care. The majority of respondents, however, did feel that some young people had needs that made them less suited for the therapeutic residential care model as it is currently offered. For example, some respondents felt that young children and those without high therapeutic needs were not good candidates for residential care. Most respondents indicated that young people with sexualised behaviours that involved coercion or with violent or high-risk behaviours associated with substance use were not suited to therapeutic residential care in its current form. Finally, young people who have reactive attachment disorder or other difficulties in forming attachment relationships were thought by respondents to need more intensive supports than were possible within therapeutic residential care. Generally, young people who negatively influence other young people or whose behaviour is characterised as non-cooperative or as coercive were thought to need augmented programs of care.
Suggestions for change focused on adjusting therapeutic models, staffing ratios and staffing qualifications to better meet the needs of young people with more complex needs. In other words, changing program designs, activities and staffing to create models that better address the needs of young people who may currently be falling through the gaps. Suggestions for program design include: reducing the use of shorter-term placements that do not allow sufficient time to build relationships with young people; referral and placement matching that considers young people's developmental level, relationship needs, and who therapeutic care is most suited to; and enhancing the focus on family, community and culture. Several comments noted the need for a continuum of options that should include secure care and/or a more specialised service model for young people with substance use issues or who are at high risk of serious physical or psychological harm to self or others. Young people with aggressive, coercive or challenging behaviour were viewed as needing more appropriate funding and staffing ratios and more skilled staff to support them.
3. How might therapeutic residential care be improved to better accommodate the needs of young people?
Thirty respondents answered this question. Several clear themes were identified:
Changes to referral, matching and transitioning pathways
Several respondents commented on the need for changes to current practice to allow young people to be assessed and properly matched to a placement - whether this is therapeutic residential care or foster care - rather than asking 'who has a bed right now?' Respondents commented on the need to legislate standards of care that ensure adequate identification of needs prior to intake, and an assessment of the ability of any service program to meet those needs. Others made more general comments about the need for systemic changes in the process of matching and transitioning, and the capacity to 'cap' placement numbers in homes to maximise stability and minimise the impact on other young people.
Specialisation of therapeutic residential care models
Participants commented on the need for a variety of specialised therapeutic models, with additional funding to ensure clinical, allied health and therapy services for young people were conducted by qualified staff with sound working relationships with the residential care staff. The need for access to specialist medical services, paediatricians, psychiatrists, clinical psychologists and occupational therapists was noted. Related to this was a perceived need for models to address high-risk behaviour, sexually harmful behaviour and substance use; and these models require higher ratios of staff and specialist mental health input. The need to maintain ongoing training and support for frontline staff was seen as essential. In addition to foundational training in therapeutic care, the need for training in supporting children with sexualised behaviour and intellectual disability was identified as important.
Adopting a child-centred approach
Several respondents emphasised the need to work with young people in a child-centred way; rather than taking a 'child protection' perspective. This may reflect participants' belief in the need to adapt the service options to better suit young people's needs (i.e. work to accommodate a child's unique needs in a 'child-centred' way), rather than offering one model that a young person is required to adapt to (i.e. a 'one-size fits all' child protection service model).
According to participants, this included affording young people more autonomy and choice about decisions, promoting their independence in more effective ways, and offering a variety of models that are designed around young people's needs. Effective models could also include secure care for young people at particular times when they are unable to keep themselves safe, but also other models designed to wraparound young people. Participants described the need for better integration of care between juvenile justice, policing, and care and protection systems to ensure the safety of young people was prioritised, to avoid criminalisation of need and to ensure that young people can stay at the residential home long enough to benefit from therapeutic support.
Participants commented that a child-centred (rather than systems-centred) approach should also include more effective collaboration between services, service coordination and communication with young people in residential homes; and cross-government initiatives that include health, mental health, education and child protection working together to achieve better outcomes for young people in the care 'system'.
Finally, comments were made about the need to create a more 'normal' childhood experience for young people; as many aspects of the residential 'system' meant young people experienced unnecessary restrictions on their participation in friendship groups or other social groups, and were disconnected from family relationships and their broader cultural community. These comments may refer to practices such as police checks for sleepovers or physical re-location of young people away from community, which may create barriers to social connection that are not experienced by other young people. Suggestions for normalised and child-centred care put forward would have funding and staff training implications that fall outside current service parameters.
Providing secure care intensive options for young people at risk
Several respondents commented more specifically about the need for a secure therapeutic careoption for a proportion of young people; and that longer periods of time and more active therapeutic engagement is sometimes required than is available under current models in order to prepare young people for independence and living in a less restrictive environment. Secure care containment options were seen as beneficial for young people who regularly leave residential facilities to engage in drug use, and cannot be engaged in rehabilitation or detoxification within the constraints of the current therapeutic care model. The need for secure care to be well considered, appropriately funded and time limited was noted. The need for programs that address alcohol and substance use was also noted, especially outside of metropolitan areas where there are fewer treatment options.
A range of comments were made about potential changes to existing legislation that may facilitate/support the provision of more effective therapeutic care. This included the need for a range of options other than 12-month or 18-year orders;as well as legislation mandating access to therapeutic supports for young people in care. Participants also expressed the desire for mandated standards of care that ensure young people's needs are identified prior to intake, and that services are assessed on the ability to meet young people's needs and the service's duty of care to young people. Finally, there was a call for legislative standards and 'factually sound reasoning with evidence' regarding decision making; in particular, regarding criteria for deciding whether a child is 'at risk', or in recommending a change in placement for a young person in care.
Flexibility in service commissioning models
Participants commented on the need for more flexible models and for funding of care outside of a four-person model; including the capacity to 'cap' the number of young people and/or fund additional staff in a home when it is necessary (e.g. to stabilise a home). Related to this, there was a suggestion to allow groups of two (especially siblings) to live together without having to place another child in the home due to funding model requirements that stipulate the number of children to be placed in each home. Generally, higher levels of funding were viewed as a means to ensure two staff were on shift at all times, and for more flexibility in responding to young people's changing needs. Comments were also made about the impact of regional contracting models, which meant that young people cannot easily move into homes in other regions; and about the need to separate contract compliance from service delivery reporting. As a whole, participants' comments appeared to suggest that aspects of the referral and commissioning of services affected services' ability to respond in a flexible way to young people's needs.
Participants commented on the complexity involved in decisions about the suitability of therapeutic residential care for young people. As a whole, participants recognised that a young person's engagement and relationship skill, often related to a young person's age and time spent in care, was a factor in determining whether therapeutic care or a more specialised and intensive model would be suitable. It is worth noting that there is considerable debate about the suitability of therapeutic residential care for young children; although it may be, at times, the only option for larger sibling groups that include younger children (McLean, 2015). Generally speaking, participants raised several possible ways in which therapeutic residential care could be adapted to make it more suited to young people with additional and complex support needs, including building more flexible and responsive referral pathways and augmented models of care, based on need.
4. Key issues informing future development in the sector
- There were variable views about which young people could most benefit from therapeutic residential care - whether all children could benefit from this service or those who needed high levels of supervision, or had complex behavioural, emotional or relationship needs.
- Views about the age range for therapeutic residential care were also mixed - some felt younger children offered more potential for change, others felt that older children and adolescents were more suited to this form of care.
- Respondents felt that young people with certain complex needs, coercive interpersonal relationships or high-risk behaviours were not suited to therapeutic residential care in its current form, and needed additional specialised input and programming.
- There was a perceived need to tailor models in consideration of young people's developmental, therapeutic and safety needs, resulting in a range of models that should include secure care to address prescribed needs. This should accompany greater legislative and funding flexibility.
- The need for changes to the referral, matching and transitioning pathways was noted, in order for there to be better alignment of services with need.
- The need for services to better respond to children's developmental need, rather than statutory concerns, was noted (be 'child-centred' not 'child-protection' centred).
1 Note, there is some variation in how these models may be conceptualised and operationalised in practice. Broadly speaking, each of the models described here are characterised by different underpinning beliefs that inform practice. For example, attachment models rely on providing young people with the experience of safe and nurturing relationships as a means for facilitating change and growth. Developmental models view behaviour in terms of missed developmental opportunities, conceptualised within the range of typical child developmental experience, and emphasise the provision and scaffolding of normative developmental opportunities to provide the opportunity to address developmental gaps. The Teaching Family Model and other social learning models rely on the appropriate use of boundaries paired with modelling of desired and prosocial behaviours, together with competency building, as a foundation for providing corrective experiences to young people. The Teaching Family Model specifically uses house 'parents' to support a social learning program and to build prosocial responses. Behavioural models are similar to social learning models of practice but may rely more on managing environmental triggers and contingencies. A Positive Peer Culture model is a model for developing prosocial peer influence, and social and cultural responsibility, based on group norms and problem solving. For more information about these models see McLean, Price-Robertson, & Robinson (2011) or McLean (2018).
2 Neurosequential programming is an approach to developing therapeutic supports for vulnerable children that is based on understanding the timing and nature of past abuse, coupled with a mapping of the impact of the abuse to the developmental stage, brain region and neural networks thought to mediate neuropsychiatric difficulties. Therapeutic supports are shaped by this knowledge and delivered in the context of trustworthy relationships with significant others. This approach was developed by Bruce Perry and colleagues, and has been influential in shaping practice in out-of-home care in Australia (see McLean, Price-Robertson, & Robinson, 2011; Perry & Hambrick, 2008).
Polyvagal theory draws on knowledge of human evolution and the physiology of neural circuits to explain the interplay of adaptive and non-adaptive physiological responses in response to threats to safety (see Porges, 2007, for more information).
PACE is an approach that forms part of Dyadic Developmental Therapy. This approach was developed by Dan Hughes and it promotes what he believes are principles of therapeutic relationships that caregivers should aim to display towards young people: Playfulness, Acceptance, Curiosity and Empathy (PACE) (see ddpnetwork.org/about-ddp/meant-pace/ for more information).
3 Secure therapeutic care in this context refers to a facility or service that is legislatively supported to provide time-limited secure care for young people who are at substantial and significant risk of harm to themselves or others. The rationale for referral to secure care rests on the argument that the child's best interests may be served by eliminating their exposure to harm through temporary removal from risk by placement in secure care. The key considerations in this form of care (both internationally and in the Australian jurisdictions where this is available) involve the need for clear referral criteria, supportive legislation and oversight, strictly time-limited models, presence of step-down pathways; access to mental health support; active case management; and the explicit recognition of neuro-diversity, intellectual impairment and trauma as predisposing and perpetuating factors driving young people's risk. For a more detailed discussion of secure therapeutic secure care in Australia and internationally, see McLean (2016).
4 '12-month orders' in this context refers to a ruling that awards short-term/temporary custody of a child - typically to a guardian other than the child's biological parents - for a defined period of time (typically 12 months). '18-year orders' in this context refers to a child's legal custody being awarded to a senior statutory authority, until such time as the child becomes an adult.