Therapeutic residential care in Australia: Taking stock and looking forward
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Sara McLean, Rhys Price-Robertson, Elly Robinson
Therapeutic residential care (TRC) is becoming an increasingly relevant out-of-home care option for children and young people with multiple and complex needs. It is a new and developing approach in Australia, one aimed not simply at containment of the hard cases as is often the case in traditional residential care but rather at actively facilitating healing and recovery from the effects of abuse, neglect and separation from family. In this Issues Paper, therapeutic residential care is described and contrasted with other models of out-of-home care. The theory and evidence supporting the use of this form of care are examined and used to develop a set of key elements, which, it is argued, should guide the provision of therapeutic residential care in Australia.
Following the move towards deinstitutionalisation in the second half of the last century, residential care was a mainstay placement option for children and young people who were unable to remain with their family due to protective concerns. More recently, however, it has become a last resort, used when other approaches, such as family support and/or foster care, have not been successful (Bath, 2009). Young people who display highly challenging and disruptive behaviours, such as those associated with conduct disorders, neuro-developmental problems and mental illness, are most often referred to residential care in order to avoid them harming themselves or others (Bath, 2009).
There is, however, an increasing understanding that these young people’s histories are often littered with experiences of abuse, neglect and multiple placement breakdowns, which can hinder their ability to build trusting relationships with others. Many of these young people show signs of complex trauma and post-traumatic stress disorder (van der Kolk, 2005), which contribute to their maladaptive behaviours and emotions. Consequently, there is a growing shift to move beyond a traditional residential model of daily care and accommodation to a needs-based model of care that addresses the challenges posed by these young people’s often compromised and complex developmental needs (Bath, 2009).
This growing interest in how best to offer a healing, therapeutic environment within the context of residential care led to a proposal to hold a national workshop, which was endorsed by the Community and Disability Services Ministers’ Advisory Council (CDSMAC) in late 2009. The National Therapeutic Residential Care Workshop was subsequently held in Melbourne in September 2010. The workshop brought practitioners and service providers together with researchers and government policy-makers. This paper draws on the proceedings of that workshop, Australian and international literature, and information about current models offered by jurisdictions within Australia to provide a picture of the increasing investment in therapeutic residential care and the key elements that characterise this model of care.
Definition of therapeutic residential care
One of the tasks of the National Therapeutic Residential Care Workshop was to provide a range of descriptions of therapeutic residential care that could be used in the development of a national definition. The definition has been refined at length by the national working group, and the final version is presented in Box1. The definition has been developed to allow for various interpretations, according to the needs and scope of therapeutic residential care in different jurisdictions.
Box 1: National definition of therapeutic residential care
Therapeutic Residential Care is intensive and time-limited care for a child or young person in statutory care that responds to the complex impacts of abuse, neglect and separation from family. This is achieved through the creation of positive, safe, healing relationships and experiences informed by a sound understanding of trauma, damaged attachment, and developmental needs.
Source: National Therapeutic Residential Care
Residential care in Australia and internationally
Therapeutic residential care reflects a response to the need to provide out-of-home care service solutions applicable to the unique Australian context, in which demographics, geography, culture and care needs can differ in many respects from those found outside Australia. For example, greater population and geographic density in countries such as the United States or Canada means they have the capacity to justify the funding of larger residential homes with higher levels of specialist staffing (Ainsworth, 2007). As such, models developed in response to the service constraints in other countries cannot necessarily be directly and meaningfully translated to the Australian service and policy context. Nonetheless, such comparisons can help to identify solutions and innovations that might be useful in developing and refining existing models.
Comparing and contrasting therapeutic residential care in Australia to international forms of out-of-home care, and particularly to different types of residential care, is complicated by the absence of clear definitions and conceptualisations of the different forms of care (James, 2011; Knorth, Harder, Zanberg, & Kendrick, 2008). The specific treatment or therapeutic components of different residential care programs are rarely elaborated, rendering much of the residential service provision a “black box” of poorly understood elements that are difficult to generalise from or replicate (Hoagwood & Cunningham, 1992; Knorth et al., 2008). Comparison is also complicated by the continuing effect of traditional social and welfare models and values (Bath, 2009).
Out-of-home care service provision can also vary widely in ideology, structure and design. Models of service provision for children may differ conceptually in terms of their goals, the nature and “restrictiveness” of the intervention, and the staffing and support configurations attached to each. In the case of residential services, such services could be designed for children with mental health or behavioural problems, for juvenile offenders, or for those placed in out-of-home care for a range of reasons.
Despite these difficulties, it is possible to broadly compare therapeutic residential care, as it is currently conceived and practised in Australia, with other forms of out-of-home care. Traditionally, out-of-home care service provision has been conceptualised as occurring along a continuum of service options (Stroul & Friedman, 19964). Service models range along this continuum from the least intrusive and requiring the lowest level of support, to the most intrusive and support-intensive. Historically, residential care in all forms has been provided as a point of “last resort”, rather than a “first placement” option, as mentioned previously. Children often end up in residential care following multiple placement failures, and it is said that children can “fail” their way into residential care.
Box 2 summarises the full range of potential configurations of out-of-home group care that exist internationally for children. The range of options represents what currently exists internationally, and not all of these models of out-of-home care services are employed in the Australian context. The service configurations summarised in Box 2 represent a continuum of care options, including those that are not exclusively used for children who have been removed from home due to abuse or neglect. Where possible, the service model is compared or contrasted to current Australian service provision.
Therapeutic residential care shares some components of psychiatric hospital/secure treatment unit care, and has many features in common with both treatment or therapeutic foster care and residential treatment care (see Box 2). Thus, while the residential treatment care model, for instance, does not appear to exist per se in Australia, elements of this approach (e.g., therapeutic milieu) have been adopted in ideology in therapeutic residential care.
Therapeutic residential care is also unique in a number of ways. While it aims to facilitate healing of interpersonal trauma, it may do so largely without the intensive input of a multidisciplinary professional team such as exists in residential treatment care (see Box 2). It can be also be distinguished from treatment or therapeutic foster care or family group care because the aim is to provide a therapeutic service in a staffed, residential group home or cluster of homes, rather than to support therapeutic foster parents to carry out a program of intervention. Most residential care currently operating in Australian jurisdictions falls between family group care and staffed group care/congregate care models, supported by specialist consultancies.
Box 2. Range of out-of-home care support options
The following list of out-of-home care support options used in Australia and internationally leads from the least intrusive and requiring the lowest level of support, to the most intrusive and support-intensive. These service options are designed for a wide range of clients (not exclusively children in out-of-home care) and offered by a range of service providers (e.g., in mental health, juvenile justice or child welfare), making direct comparisons between models difficult. Delfabbro, Osborn, and Barber (2005) have suggested that out-of-home care services can be conceptualised as offering diverse care environments; for example, in regard to staffing configurations (on-site or “wrap-around” specialist support; treatment or containment role for staff), aspects of the physical setting (community or institution location; single unit or multiple dwellings; size of unit), and the management of the care environment (behavioural sanctions; orientation to care). The following are some of the support options that are reported in the international literature (see Stuart & Sanders, 2008, for more detail).
This is a form of home-based care provided by families who will take children on short notice for limited periods of time while long-term alternatives are organised. Although not commonly used in Australia, these can be considered to be analogous to emergency foster placements.
Kinship care is the provision of home-based care for children by adults who have a kinship bond with the child. This form of care is considered the most appropriate for children for whom it is important to maintain family and broader cultural connections; for this reason it is the first choice for Indigenous children in Australia.
Conventional foster care
This refers to the provision of home-based care by unrelated non-kin adults, and is a commonly used option for children who are removed from their homes due to abuse or neglect.
Treatment foster care (specialised or therapeutic foster care)
This is home-based care provided by foster carers who are recruited and trained to care for children in a therapeutic, trauma-informed way. These caregivers are typically reimbursed at a higher rate than conventional foster carers, in recognition of the complex needs of the children that they care for. It is well utilised in North America, where it may be employed for children with special needs or juvenile offenders. In Australia, there has also been increasing acknowledgement of the need for specialised or therapeutic foster care models to respond to the complex emotional and behavioural needs of children in out-of-home care. Treatment, specialised and therapeutic foster care can differ widely depending on the therapeutic framework used.
Family group care
This is similar to treatment foster care; however, the foster parents are also supported by workers on a shift basis. The home may be owned by the service provider, with the foster parents “living in”. These homes may be larger than specialised or treatment foster homes, and may or may not exist in a cluster in close proximity to each other. This model of care does not appear to be widely used in Australia.
Congregate care (staffed group care or residential care)
Congregate care is provided in community-based residential homes, in which workers provide direct care of children on a rostered or shift-work basis. In Australia, these models have not typically received input or support from multidisciplinary teams or consultants, and do not necessarily provide a therapeutic or treatment aspect to children by design.
Therapeutic residential care
This intensive care placement for young people in statutory care within a residential setting aims to address the complex impacts of abuse, neglect and separation from family. This is achieved through the creation of positive, safe, healing relationships and experiences, informed by a sound understanding of trauma, attachment, and developmental needs. This option is “time-limited”; that is, efforts will be made to address critical issues and behaviours first before the young person is transitioned into a foster care placement. This emerging model is increasingly being suggested to represent optimal therapeutic care for children in the Australian out-of-home care environment.
Residential treatment care
Residential treatment care involves managing a fully staffed group home or a large campus under a common clinical supervisory structure, which may include day treatment programs or “on-site classrooms”, and a multidisciplinary clinical support unit. These are not exclusive to young people in out-of-home care, and are generally of a time-limited nature. The residential treatment model may have a well-articulated theoretical framework—typically focusing on either mental health or educational/ training needs—using a therapeutic milieu or specific (cognitive/social) skills training, and may involve biological families in treatment.
Psychiatric hospital (secure treatment unit care)
These institutions contain all of the main ingredients of a residential treatment centre, but with the additional capacity to medicate or certify/secure a young person if they are considered a danger to themselves or others. They are not provided exclusively to children in out-of-home care and generally provide short-term care for children with acute needs.
Secure care/correctional facility
These are locked facilities to which young people are sent by court order, typically but not always as a consequence of criminal misconduct,which are not exclusive to children in out-of-home care and do not generally provide therapeutic input. In the Australian out-of-home care sector, this option can be enacted for children when the Children’s Court deems that there are serious concerns for the safety and wellbeing of the child on a protective order (used in some jurisdictions).
Source: Stuart & Sanders (2008)
Therapeutic residential care is a response to the unique population, geography, economic constraints and out-of-home-care landscape that exist in Australia. While it is clear that therapeutic residential care is a new model of service provision, it does share a number of components with some other out-of-home care models that have been used internationally. Although it sits at the more intrusive and support-intensive end of the continuum of out-of-home care, there are moves to position therapeutic residential care as a mainstay placement option, rather than simply a last resort for the hardest cases.
1 Victoria, for example, has secure welfare that is a short-term placement option when there are serious concerns for the safety and wellbeing of a child on a protective order. This is not provided in relation to criminal behaviour.
The current state of therapeutic residential care in Australia
Early in 2011, information was requested from the eight Australian child protection jurisdictions on the structure and functioning of the therapeutic residential care services available within the jurisdiction (if any), the characteristics of the service users, and the particular service models or practice frameworks utilised. The intention was to present a cross-jurisdictional comparison, but the results of the survey indicate that there is considerable variation in the ways in which therapeutic residential care is being defined, developed and undertaken. While, as a result, the cross-jurisdictional comparison was not feasible, the following section presents a broad summary of the responses in order to give some insight into current practices in Australia.
There was consistency in the way in which target groups for therapeutic residential care were described across jurisdictions. Many of the children and young people in therapeutic residential care had a history of abuse and neglect, and trauma caused by these repeated events was a pervasive backdrop to current challenges. Such children and young people exhibit a range of social, emotional and educational difficulties and complex/extreme behaviours, some examples of which are:
- recurring and often severe self-harming behaviours, including suicide attempts;
- a history of running away and prolonged absences;
- multiple placement disruptions due to behaviour;
- sexually inappropriate behaviours;
- mental health problems;
- antisocial behaviours, including violence and aggression towards others;
- alcohol and substance abuse;
- cruelty to animals; and
- developmental delays or disabilities.
What differentiates young people in therapeutic residential care from other forms of care is that problems normally occur with significant frequency and affect day-to-day functioning in a highly adverse manner. Additionally, in many cases, there is a history of unsuccessful attempts to manage difficulties and behaviours, which points to the need for a more holistic, structured therapeutic approach.
Staffing structure of facilities
The jurisdictions differ somewhat in terms of the staffing structure within facilities. Some have clinical specialists working full-time or part-time alongside other trained staff. In other jurisdictions, all staff members receive training in trauma-informed care, and residential psychologists are available to support staff in providing care, but a full contingent of clinical specialists is yet to be achieved.
The amount and type of specific training offered to staff also varies to some degree across the jurisdictions. Some jurisdictions offer residential care staff induction training in trauma-informed care and access to ongoing training in areas such as child development, brain development and the effects of trauma, and therapeutic crisis intervention. The training requirements of other jurisdictions are slightly more extensive, with workers in therapeutic residential care homes being required to participate in an initial two-day introductory training, followed by a five-day training program that is specific to the facility in which they will work. Of course, all such training is additional to the requirements necessary for employment in each particular jurisdiction.
Promising and problem practice elements
The jurisdictions were asked about what they saw as the most promising practice elements in their therapeutic residential care programs, as well as the elements that were less likely or had been shown not to work. Some jurisdictions indicated that an understanding of the effects of trauma on the functioning of the brain, as well as skills in responding to pain-based behaviour, had led to positive behavioural changes in children and young people. It was also noted that a strong emphasis on the provision of evidence-based practice and on well-articulated care and case plans appeared to be among the most promising practice elements.
In terms of program elements that were not working as well, one jurisdiction indicated that staff expectations of the therapeutic residential care model were often too high, which could result in disappointment when the service users’ problematic behaviours continued. It was also noted in this jurisdiction that there were difficulties in attracting and retaining appropriately experienced and trained management and care staff. Finally, a number of jurisdictions mentioned that developing congruence across the multiple government and non-government agencies involved in the provision of therapeutic residential care has proved to be quite difficult.
Service models or practice frameworks
The jurisdictions were further asked about the particular service models or practice frameworks that informed the operation of their therapeutic residential care programs. Although there are region-specific influences on the structure of practice frameworks—such as state/territory legislation or practice frameworks that have previously been adopted by their jurisdiction’s child protection services—there are, in general, a number of key models and frameworks that were drawn on by the jurisdictions when designing their own therapeutic residential care programs. At a theoretical level, the field of therapeutic residential care has been heavily informed by attachment theory, trauma theory, the neurobiology of attachment and trauma, and the concept of resilience. Many of the jurisdictions explicitly noted that their programs were underpinned by these theories and concepts. At the program level, Anglin’s (2002) “congruence in service” approach has been highly influential in the field, with every jurisdiction explicitly drawing on this approach. The Sanctuary® model of care (Bloom, 2005) has also informed the structure of many of the jurisdictions’ services. These models are discussed further in the following section.
Theoretical underpinnings of therapeutic residential care
Therapeutic residential care seeks to provide a healing environment for children in statutory care that is sensitive and responsive to the trauma (see Box 3), attachment, loss and developmental history of the young person. The model is underpinned by a recognition of the importance of specialist supports, healthy relationships and good communication between all stakeholders. It is a time-limited and intensive support model in which the ultimate goal is to strengthen young peoples’ positive relationships and to support the young person to transition to a preferred care environment, such as a family-based foster care placement, or to independent living.
Box 3: What is trauma and trauma-informed care?
Central to therapeutic residential care is an understanding of trauma and its effects. Trauma theory provides a very useful framework for understanding behaviours and outcomes seen in young people with past histories of violence, abuse and neglect. Trauma is the overwhelming and uncontrollable feeling of intense fear, helplessness and loss of control in response to terrifying life events. Trauma may be experienced as:
- a single traumatic life event, such as rape, a near-death experience or witnessing the torture or abuse of another person; or
- prolonged and repeated events, which is often the case when trauma occurs within an interpersonal relationship or a domestic context, as in domestic violence or child abuse (Courtois, 2008; Herman, 1997).
Traumatic events can induce a wide range of debilitating symptoms that affect all aspects of life for survivors. Trauma-informed care involves understanding the possible effects of trauma, as well as the practices or interventions that may facilitate healing. This knowledge better enables practitioners to determine the underlying causes of a young person’s problems, and enables them to more effectively assist the young person to make positive life changes.
The conceptual development of therapeutic residential care in Australia has been influenced by the writings of James Anglin (Anglin, 2002), Sandra Bloom (Bloom, 2005) and Bruce Perry (Perry, 2006). These authors have emphasised the importance of having synergy or “congruence” between the service provider’s workers and organisational culture, and have drawn attention to the influence of children’s traumatic pasts in determining their present behaviour. All jurisdictions surveyed acknowledged at least some of these key theoretical contributions, which are outlined below. The section following then reviews the research literature on residential service provision in more detail.
The conceptual work of both Anglin (2002) and Bloom (2005) highlights the importance of having a well-developed and consistent organisational culture and theoretical approach to residential care. Both authors stressed the need for congruence at all levels of service provision and for a framework that provides a common language for organisational and worker–child relationships. The importance of quality and safety in relationships is also acknowledged in addressing disrupted attachments and relationships.
The concept of trauma-informed and trauma-sensitive care has also been at the core of the emerging framework for therapeutic residential care. Bloom’s (2005) work in describing the Sanctuary® model of care highlighted the importance of having an organisational culture that is trauma-informed and that provides both safety and an environment in which trauma can be explicitly addressed (Rivard, Bloom, McCorkle, & Abramowitz, 2005). Perry’s writings (e.g., 2006), from the field of neuroscience, have also highlighted the significant impact of early abuse, trauma, and disrupted attachment relationships on the developing brain. Perry further discussed the ways in which individual strategies for regulating emotional arousal can help to offset the effects of these early experiences.
Unfortunately, however, at this stage, these theoretical frameworks fall short of providing concrete guidance for developing therapeutic interventions that may be suitable in residential care settings. The Sanctuary® model (Abramowitz & Bloom, 2003) is perhaps exceptional in that it has articulated the specific components of the residential environment and the psycho-educational group work that is central to its trauma-informed model. The extent to which these components can be successfully adopted by different service users in an Australian context, however, is unclear.
While the development of therapeutic residential care may have been informed by sound practice principles, our knowledge of the effectiveness of these ideas is limited. At this early stage, the evidence base for therapeutic residential care is underdeveloped, and ongoing evaluation is required. Therefore, it appears timely to reflect upon what the literature can and cannot tell us about the efficacy of other forms of residential care (e.g., residential treatment care), and examine how this resonates with the development of therapeutic residential care in Australia.
Therapeutic residential care is underpinned by a number of models that, taken together, serve to focus attention on workers and services being trauma-informed and providing consistent high-quality relationships.
This kind of conceptual work has greatly facilitated the shift to viewing residential care as a potentially therapeutic form of support, rather than a “last resort”.
However, these models and theories are often unable to produce concrete guidance for developing therapeutic interventions, and there is currently limited evidence supporting the overall efficacy of therapeutic residential care.
What does the research literature tell us about the effectiveness of residential care?
One of the difficulties in drawing on the international research knowledge about residential care is that residential care outside of Australia is a placement option that exists at the intersection of three major service systems—statutory child welfare, child mental health and juvenile justice (James, 2011). This means that those attempting to synthesise the literature are not readily able to compare studies of similar design, delivered to similar populations or using similar outcome measures.
Despite this difficulty, outcome studies have been conducted, and they indicate the potential for residential care to contribute to improvements in psychosocial outcomes for children. On average, most children do improve in psycho-social functioning following a period in residential care (Curry, 1991; Knorth et al., 2008). From the perspective of research and outcome evaluations, evidence for the effectiveness of residential models of care comes from a body of research on residential treatment care models and some promising smaller group care models or other well-known models that have been subject to limited quasi-experimental evaluations (for examples, see Appendix 1).
The bulk of the published outcome literature examines the efficacy of residential treatment care, and therefore this is the main literature that will be outlined below. Residential treatment care tends to be provided in larger facilities, have a mental health focus and be administered by multidisciplinary teams (Curtis, Alexander, & Lunghofer, 2001; see Box 2 for further information). Reviews of this model of care suggest the following:
- The effectiveness of residential care is related to characteristics of the child’s need. Young people with externalising behaviour problems (e.g., antisocial behaviours, hyperactivity) appear to make more progress in residential treatment programs than young people with internalising problems (e.g., anxiety, social withdrawal) (Knorth et al., 2008). The nature of the child’s need (i.e., the type and severity of difficulty and the nature of onset) are likely to affect outcomes (Curry, 1991; Knorth et al., 2008), and serious consideration should be given to matching the service or program design to the child’s needs. For young people involved in juvenile offending, there is research evidence to show that providing them with specific skills training (empathy and social problem-solving) and using behavioural strategies and techniques together with family-focused therapy is useful (Knorth et al., 2008). The efficacy of residential care should be considered in the context of the child’s developmental needs (Barth, Greeson, Zlotnik, & Cintapalli, 2009). The impact of many therapeutic interventions is also likely to be influenced by a child’s cognitive development and reflective capacity (Stevens, 2004), but for children with intellectual delays, identifying and building functionally equivalent alternative behavioural skills may be more effective.
- The effectiveness of residential care may be related to engaging more widely with the child’s supports. Establishing and maintaining family contact, to the extent possible, is paramount to a complete understanding of a young person’s needs, identity, attachment and heritage (Connolly, 2009). From a service perspective, there is clear support for the inclusion of family-focused interventions for young people with severe behavioural problems (Knorth et al., 2008; Leichtman, Leichtman, Barber & Neese, 2001) and for the inclusion of other networks in the assessment, residential care and post-care support phases (Curtis et al., 2001; Frensch & Cameron, 2002; Hair, 2005). Residential care workers can engage with family and community connections, who are often physically distant from the site, rather than having the family work being divorced from the program and left to case managers (Hillan, 2006). Conceptually, this is often framed as an ecological model, embracing family and community involvement when possible, including in post-care planning (Bay Consulting, 2006; Hair, 2005). Additionally, the program should have active strategies for engaging with or developing the young person’s educational, training and/or work experience network, because academic success and support are related to positive outcomes (Curtis et al., 2001; Hair, 2005).
- Without post-care support, the impact of residential programs may be time-limited—short-term gains may be greater than long-term gains (Knorth et al, 2008). Although most young people improve during residential care, improvement during care is not a good predictor of long-term outcomes when they return to the community (Leichtman et al., 2001). For this reason, well thought-out and ongoing support post-care appears essential (Curry, 1991; Knorth et al., 2008). Consideration should be given to creative solutions for post-care support issues, including the possibility of children and families keeping in contact with unit staff in order to continue to benefit from professional and informal supports.
The literature examining the efficacy of residential treatment care (which is similar in a number of ways to therapeutic residential care) suggests that the success of residential care is related to characteristics of the child’s needs, wider engagement with the child’s supports, and the provision of post-care support.
What can practitioners and other experts tell us about what might work in residential care?
Although there is limited research evidence into the efficacy of the different forms of residential group care, a number of respected researchers and practitioners have argued that there is a number of core components to effective service provision. Irrespective of which theoretical model informs residential care practice, it has been argued that effective residential care needs to incorporate: (a) a clearly thought-out philosophy of treatment or care (Clough, 2008; Hillan, 2006); (b) child-centred practice, in which service provision is matched and responsive to the child’s need, rather than the child’s needs being subordinate to the service model (Clough, 2008; Hillan, 2006); and (c) a service-wide commitment to staff support and continuous learning (Hillan, 2006).
Clearly articulated philosophy of care
The body of research that specifically examines the effectiveness of residential care is largely restricted to experimental studies of residential treatment care. There are other potentially helpful design or treatment elements or programs that have been subject to quasi-experimental outcome assessments and provide insight into potentially effective practice (see Appendix 1 for descriptions of these promising group care models). Well-established models such as the Sanctuary® model (Bloom, 2005), for example, incorporate cognitive-behavioural strategies such as assertiveness training, relaxation skills, social skills and social problem-solving strategies, as well as psycho-educational strategies that explicitly educate children about trauma and therefore enable children to make sense of their own traumatic interpersonal history. There is a clearly articulated framework for therapy, staff–client relationships and for negotiating the residential environment.
Approaches that emphasise a positive peer culture (Vorrath & Brendtro, 1985)—a norm of care and responsibility for self and others—may also be beneficial. Programs derived from this model that promote the positive value of helping others (Quigley, 2004), correction of negative cognitive biases (Gibbs, Potter, & Goldstein, 1995), strategies for anger management (Goldstein, 1998), and notions of restorative justice (Steiner & Johnson, 2003) have also been advocated (Ainsworth & Hanson, 2008; Handwerk, Field & Friman, 2000). Programs that assume and encourage a child’s need for mastery, belonging, independence and expression of prosocial behaviour also show promise (Brendtro & Brokenleg, 2001). Although diverse, these programs may all be characterised as emphasising strengths, developmentally appropriate skill development, and encouraging community belonging, in contrast with a problem focus or deficit model.
Outside of residential care, highly effective treatment programs for young people with extremely challenging behaviour (i.e., multidimensional treatment foster care) (Chamberlain, 2003), include elements that might be adopted in the residential environment. For example, continuity of care, high levels of support for carers, complimentary individual behaviourally focused and (biological) family therapy, cooperation with school, justice and health, and coordination through case management. These elements of successful intervention could possibly inform the future development of residential care (Knorth et al., 2008; McCurdy & McIntyre, 2004)
Child-centred and responsive models of residential care
In Australia, traditional residential care units have often been seen “more as containment centres rather than as places where therapeutic interventions could be concentrated” (Delfabbro et al., 2005, p. 16). A young-person-centred approach, in comparison, is supported by literature and best practice as focusing on the needs and interests of the young person (Connolly, 2009). Delfabbro et al. (2005) argued that more effective service design may be arrived at by moving away from a paradigm in which residential care is seen invariably as a restrictive placement of last resort. In addition, a focus on the assessment of clinical issues and needs is critical (Hillan, 2005). Clearer consideration of the child’s needs would mean that residential care could be used differently; for example, to provide respite for families, or to support graduated family reunification or shared care arrangements, rather than being a placement of last resort (Stuck, Small, & Ainsworth, 2000).
In cases where intensive support is required, Ainsworth and Small (1995) have argued that this may best be delivered in a large-scale model of care, similar to treatment residential care models in North America. The opportunity to bring together multiple professionals on the same campus or location (e.g., educational staff, court officers, psychologists, health workers and vocational counsellors), such as used extensively in North America, has been largely unexplored in Australia (Delfabbro et al., 2005). This could also be provided in smaller residential homes through the provision of “wrap-around” specialist services (Delfabbro et al., 2005), because the potential negative effects of bringing together children with difficult, aggressive behaviour has been noted (Dishion, Bullock, & Granic, 2002). Therefore, there is a pressing need to consider what form of residential care and at what point in a child’s life can best support a child’s mental health, behavioural, learning, family relationships and community connection needs. This may ultimately result in better alignment of residential service provision with those needs (Delfabbro et al., 2005; Stuck, et al., 2000).
Commitment to staff support
The way in which a therapeutic residential care setting is staffed will be highly influential in the success or otherwise of its work with young people. Perry (2010) argued that it can be preferable to be understaffed with the right people than to have adequate numbers of ineffective staff, bearing in mind that the best workers are the most sought after, which puts them at risk of burnout. Residential staff members are likely to make a lasting impression on young people, and strong, caring worker–client relationships can help a worker to build feelings of safety and positively influence a young person’s behaviours and attitudes (Connolly, 2009).
Effective staff members are likely to have self-awareness of the impact of their own life events on their work, which will help them to respond effectively to young people and work ethically and purposefully (Connolly, 2009). A range of competencies is important across the staffing base, as it is an unrealistic expectation for one worker to fill all roles, and young people will benefit from differing strengths of different workers. Perry (2010) described this as being able to go from worker to worker for different needs—one worker may engage in the best “horseplay”, while another gives the best shoulder massages and yet another engages in sporting activities.
From a service perspective, providing staff members with a coherent strategy and conceptual framework for understanding and addressing challenging behaviour, as well as a strategy to manage risk and de-escalate behaviour during critical incidents, while also maintaining their relationships with children in the unit, is likely to be valued. An organisational commitment to staff training and support in preserving worker–child relationships in the context of emotionally demanding work is therefore important (Hair, 2005).
Findings from a UK national survey of the mental health of young people in care indicated that 72% of young people in residential care have a mental health issue: 60% were classified as conduct disordered and 18% as having an emotional disorder (Meltzer, Lader, Corbin, Goodman, & Ford, 2004). The effective residential care worker needs to have the ability to work with emotionally charged day-to-day encounters, while maintaining positive relationships and a focus on the child’s strengths and social competencies, rather than their problem behaviour (Anglin, 1999). Increasing levels of aggression shown by young people in residential care have been argued to lead to high levels of stress and sickness in staff (Colton & Roberts, 2007), meaning that training and support in the management of children’s pain-based behaviour (Anglin 2002) while maintaining relationships may be critical.
In any model of residential care, consideration should be given to the active provision of staff supports, as the child welfare and residential care workforce demonstrate high levels of turnover (Colton & Roberts, 2007; Curry, McCarragher, & Dellman-Jenkins, 2005). Retention rates may be improved by the inclusion of clear practice frameworks and supervision, which can serve to reduce worker stress and anxiety (Byrne & Sias, 2010). Many have also recommended the separation of clinical and administrative supervision, and fostering an organisational climate that is not characterised as being risk-averse (Byrne & Sias, 2010). Access to co-worker and supervisory support—including emotional support, support in developing a mastery (skill development and learning) orientation, active coping strategies, and having reasonable control over some aspects of the working environment—may enable workers to experience adequate job satisfaction despite high levels of emotional exhaustion (Stalker, Mandell, Frensch, Harvey, & Wright, 2007), and perhaps to deal with many of the inherent strains in their work (Colton & Roberts, 2007; Stalker et al., 2007), and in the management of behaviour in particular.
A number of authors and practitioners in the broader field of residential care have argued that successful models should include a clearly thought-out philosophy of treatment or care, child-centred service provision, and a commitment to providing staff support and opportunities for continuous learning.
What are the key elements of effective therapeutic residential care?
The emerging model of therapeutic residential care currently being developed across several Australian jurisdictions is delivered in small or home-like environments, with small groups of children. It is informed by knowledge of trauma and its impact on development and behaviour, the critical importance of worker–child relationships and the importance of organisational support and congruence. Therapeutic residential care represents a relatively recent development in the out-of-home care landscape and evaluations are currently underway in some jurisdictions that will provide important feedback to inform further development of the model. While such evaluations are to be welcomed, the available research literature can also inform the further evolution of therapeutic residential care.
When the different sources of information discussed in this paper are considered together (i.e., the discussion at the National Therapeutic Residential Care Workshop, the ongoing work of the National Therapeutic Residential Care Working Group, and the national and international research and professional opinion on effective residential care models), it is possible to identify a set of key elements of effective therapeutic residential care service provision. These key elements are outlined below, along with the specific actions or qualities that would allow them to be operationalised.
- Clearly articulated philosophy of care
- Ensure the organisation has a clearly documented statement of its values and culture that is consistent with the provision of a therapeutic care environment.
- Provide staff members with initial and ongoing training on the rationale and theoretical underpinning of the practice.
- Ensure that all care staff members understand the agreed-upon philosophy and practice.
- Ensure that staff members are able to provide a clear rationale for interventions.
- Provide staff members with structured opportunities to reflect on practice.
- Prioritisation of children and young people with complex needs who are able to benefit from the trauma-informed therapeutic approach
- Conduct comprehensive assessments of young peoples’ needs.
- Provide services to young people whose complex needs mean that their placement in a foster home may be jeopardised or is not an option.
- Child-focused program structure
- Ensure the program addresses the therapeutic needs of young people based on specialised, comprehensive and in-depth assessment.
- Ensure the program is highly attuned and responsive to the particular characteristics and needs of young people so that they can heal, develop and grow.
- Provide the capacity to incorporate specialist therapeutic input in response to young peoples’ specific needs.
- Provision of a therapeutic milieu
- Prioritise the safety of staff members and young people.
- Ensure that staff members have both relevant qualifications and experience.
- Ensure that the program and staff members provide a sense of safety, structure, acceptance and security at all times.
- Enable the program design to accommodate psycho-education about trauma, and address grief and loss issues regarding family of origin.
- Provide a stable and consistent environment.
- Encourage staff members to model prosocial behaviour.
- Place value on strong, positive relationships between staff members and young people, and emphasise these relationships as being integral to therapeutic healing.
- Trauma-based orientation to program design
- Provide specialist training for staff members in the trauma theory model and its application (e.g., effects of trauma and disrupted attachment).
- Ensure that staff members are able to identify specific behaviours and triggers as possible outcomes of trauma.
- Include psycho-education about trauma in the program design.
- Provide a safe, predictable environment in which young people are protected from re-traumatising experiences.
- Provide young people with access to trauma and loss counselling.
- Individualised therapeutic plans based on best available evidence
- Develop individualised personal treatment plans for each young person that guide the implementation of service delivery by all team members.
- Ensure that the therapeutic approach is based on a theoretical framework suited to the young person’s underlying issues and presentation.
- Ensure that personalised treatment plans are reviewed regularly.
- Provide psycho-education for young people about the trauma or abuse they may have experienced and the ways in which it is currently affecting them.
- Provide prosocial modelling and reinforcement for prosocial behavior and positive peer culture.
- Provide trauma-focused cognitive behaviour therapy.
- Provide anger management and empathy training for juvenile offenders.
- Ensure interventions and expectations are developmentally appropriate.
- Participation of young people in shaping their care
- Ensure that program and staff members listen to young people and allow them to participate in decision-making processes regarding their therapeutic program and placement.
- Clearly communicate with young people about the rationale of their care plan and give them opportunities to provide feedback.
- Ensure young people have access to advocacy.
- Engagement with young person’s family, community and culture
- Engage with young peoples’ family of origin (including siblings) where possible, and at whatever level possible (e.g., phone meetings, visits, family therapy).
- Engage with relevant stakeholders in young people’s lives (e.g., school, sporting, community).
- Ensure that young people have opportunities to remain engaged with cultural practices (especially important for those from Indigenous and CALD communities).
- Provide an approach to care that is sensitive and respectful and actively explores and seeks to understand each child’s unique circumstances and experiences arising from the impact of their culture (especially important for those from Indigenous and CALD communities).
- Support for young people to exit care and plan for post-care support
- Prepare comprehensive leaving care plans.
- Ensure early engagement of post-care people and supports.
- Encourage formal and informal opportunities to maintain relationships (therapeutic or otherwise) with workers and significant others in the unit, and to return to visit the unit.
- Evaluation framework
- Embed meaningful evaluation tools in routine documentation.
- Incorporate young people’s views in program evaluation.
- Collaborate with external research bodies (e.g., universities) for the purposes of ongoing evaluation (see Boxes 4 and 5).
- Conduct ongoing program level evaluation (see Box 5 for an example).
- Ensure that the program is responsive to the changing evidence base.
Box 4: The importance of evaluation
The currently emerging models of therapeutic care in Australia are an important step forward in offering services that focus on young people’s trauma histories and current developmental needs. The emergence of any new practice offers an invaluable opportunity to embed evaluation strategies from the outset, in order to assess whether change occurs for participants and, most importantly, whether the changes can be attributed to the intervention.
Workload, the crisis-driven nature of the work, lack of resources and resistance from staff can all make embedding research and evaluation tools in a residential environment difficult (Boyd, Einbinder, Rauktis, & Portwood, 2007; Butler, Little, & Grimard, 2009; Hair, 2005). Embedding research in practice and model development ultimately requires the support of senior staff and management, and the use of tools that have appropriate reading levels, are easy to administer and measure something meaningful (Butler et al., 2009). Challenges to the development of an evaluation culture among residential care staff can be minimised by collaboration between management, researchers and staff (Butler et al., 2009). While frequency counts of restraints and incidents of aggression may be readily attainable, as these tend to be routinely collected, they constitute a poor proxy for the psychological status of the young people participating in the program. Ultimately, there needs to be a balance between practical concerns and methodological rigour (Butler et al., 2009).
An important aspect of evaluation across current Australian therapeutic residential care services is the need to evaluate outcomes using a common set of definitions and principles. In this way, “like” is compared to “like” and a clearer view of what works becomes apparent. This may also involve establishing a set of agreed outcome measures, such as developmental outcomes or behaviours, and questions that are used to effectively measure these. Research has suggested that more emphasis needs to be placed on socially relevant outcomes, such as employment or school attendance (see Curtis et al., 2001). Curry (1991) was critical of outcome measurement that takes a “static” (p. 356) view of residential placement as an isolated event, and advocates for a process view of outcome measurement, using multiple level indicators (symptom and program components) at multiple points. This includes measures of behaviour and affective difficulties, adaptive strengths, relationship capacity, program engagement and coping styles, and measures of post-care follow-up. Routine clinical measures and screening tools may not be sufficient to capture these dimensions. As such, research is needed into the development of assessment tools tailored to the needs of children in residential care.
Performance measures of residential care should reflect practice and priorities, and be linked to external research bodies, such as universities. This calls for greater interface between researchers and practitioners so that any research can be more easily integrated into service model development. This is greatly enhanced by services having access to funds to evaluate emerging models of practice (Hillan, 2006).
Box 5 provides one example of an evaluation of a therapeutic residential care program in Victoria. While there is still a considerable amount of work to be undertaken to develop an evidence-informed evaluation strategy, this example constitutes one of the primary efforts in informing therapeutic residential care practice through evaluation.
Despite the fact that program evaluation is an important aspect of the therapeutic residential care model, there are often difficulties in integrating effective evaluation strategies into daily practice. While the frameworks and models for therapeutic residential care are still nascent and evolving, there is an excellent opportunity to embed evaluation strategies in daily practice and to develop common outcome measures.
Box 5: The Hurstbridge Farm Therapeutic Residential Care Program and regional therapeutic residential care pilot programs (Victoria)—Example of a pilot evaluation
In 2009, the Department of Human Services (Victoria) awarded Verso Consulting Pty Ltd the tender for the evaluation of therapeutic residential care models in Victoria, including the Hurstbridge Farm Therapeutic Care Program (established in 2007) and a number of new or in-development therapeutic residential care pilot programs (established in 2008–09).
The evaluation, which commenced in August 2009 and is due to conclude in September 2011, incorporated 12 therapeutic residential care pilot sites throughout Victoria. The progress of 38 young people in therapeutic residential care was tracked, with 16 young people in “general” residential care also tracked as a comparison group.*
The evaluation objectives (as provided by Verso Consulting) were to:
- identify best practice approaches for the planning, development and implementation of therapeutic residential care programs;
- develop an understanding of the effectiveness and efficiency of each element of the Hurstbridge Farm pilot site;
- clarify the specific client outcomes that should be measured;
- confirm that the client measurement tools currently in use are the best possible tools to contribute to understanding of the clients’ progress;
- develop an appreciation of how well each therapeutic residential care has performed against stated objectives;
- build an appreciation of the applicability of the key lessons from the therapeutic residential cares to generalist residential settings; and
- develop an evaluation framework for the therapeutic residential care suite of initiatives.
Evaluation activities included service modelling workshops, the collection of initial and ongoing client (and comparison group) outcomes data, consultations and workforce surveys, a literature review, case interviews, and the development of an ongoing evaluation framework. A cost, long-term benefits and short-term cost avoidance analysis was also undertaken.
Qualitative data collection methods included conducting interviews with therapeutic residential care staff and management, therapeutic specialists, a sample of young people living in therapeutic residential care homes, and representatives from relevant agencies and stakeholder groups. Quantitative data was collected using a longitudinal, time series design that tracked the wellbeing of clients by collecting data at two time points prior to entry to therapeutic residential care, and at regular time points post-entry. Progress in terms of wellbeing of clients was considered from two perspectives: improvement and outcomes over time, and in relation to a comparison group. Quantitative tools used included the Health of the Nation Outcomes Scale (HoNOSCA) and the Strengths and Difficulties Questionnaire (SDQ). The department’s Child Protection, Placement and Family Services Outcomes Framework was used to define client outcomes for the purposes of the evaluation.
The way forward
Currently in Australia, there is much energy and enthusiasm directed towards establishing therapeutic residential care as a legitimate option in the range of out-of-home care alternatives available to children and young people. This Issues Paper was borne of this energy and enthusiasm, as well as the important work conducted at the National Therapeutic Residential Care Workshop in Melbourne in 2010 and being sustained by the National Therapeutic Residential Care Working Group.
Therapeutic residential care is still a developing placement option, however, and much work remains to be done to establish it as an evidence-based form of care that contributes positively to outcomes for children and young people. It was originally planned that this Issues Paper would include a detailed snapshot of the current state of therapeutic residential care in each Australian jurisdiction. Although many of the jurisdictions were able to provide some information, it became evident that the stage of development, implementation and evaluation for each jurisdiction varied considerably. It was decided, therefore, that a detailed snapshot of the current state of therapeutic residential care in this country would, at the current time, be premature, and therefore only a broad outline is offered in the current paper.
Meaningful appraisals of therapeutic residential care in Australia will be enhanced by assuring that three components are in place:
- an agreed-upon national definition of therapeutic residential care—the definition developed by the National Therapeutic Residential Care Working Group and presented in Box 1 of this Issues Paper is intended to offer this;
- a list of agreed-upon key elements of effective therapeutic residential care, upon which service models and practice frameworks can be based—the list of key elements proposed in this Issues Paper may assist to catalyse a national dialogue around this issue; and
- a national therapeutic residential care evaluation framework—this framework, based on the list of key elements of effective therapeutic residential care, and using measures specifically designed for this population, would allow for intra-jurisdictional evaluations and cross-jurisdictional comparisons, and would be a major step towards establishing therapeutic residential care as an evidence-based placement option.
The will is there; the way forward is to continue discussion and collaboration in a steady movement towards establishing therapeutic residential care as an evidence-based care option that leads to the best possible outcomes for some of the most vulnerable children and young people in Australia.
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Examples of promising programs that may inform the development of therapeutic residential care
The Sanctuary® model, originating from the Andrus Children’s Centre in New York, is a systems-level approach that targets the entire organisation. The focus is to create a trauma-informed and sensitive environment within which specific trauma-focused interventions can be carried out. Trauma-sensitive organisational structures and trauma recovery frameworks are central to the model. These support staff to process and address those children’s needs that are seen as arising out of a traumatic background. Within the culture, the model uses a 12-week recurring program of weekly explicit psycho-education. The program also engages family members wherever possible.
The core elements include the development of a culture of: non-violence (teaching and modelling safety skills); emotional intelligence (teaching and modelling affect regulation/management skills); inquiry and social learning; shared governance (teaching and modelling self-discipline and appropriate use of authority); open communication (teaching and modelling healthy interactions and boundaries); social responsibility (social connections and healthy attachments); and growth and change (focus on hope, meaning and purpose).
The Sanctuary® model has been subject to limited evaluation. When compared with a non-randomised control group (residential treatment as usual), youths who undertook programs based on the Sanctuary model demonstrated improvements in the areas of interpersonal conflict, personal control, verbal aggression and problem-solving skills (Rivard et al., 2005). Measures of “therapeutic culture” at six-month follow-up also picked up changes on dimensions of the organisational environment that are considered essential to a trauma-sensitive culture.
The Stop-Gap model, originating from the Devereux Centre for Effective Schools in Pennsylvania, is a short-term residential group care model specifically targeted at children with disruptive behaviour disorders (McCurdy & McIntyre, 2004). The program has two main treatment components: (a) the provision of environment-based interventions, and (b) discharge-focused services. Environmental interventions include the use of a token economy (i.e., a reward system for preferred behaviours), academic support, explicit teaching of social skills and problem-solving and anger management skills. At the same time, active planning related to discharge, such as parent behaviour management training, community integration and ongoing case management is implemented. More problematic behaviour is addressed by intensive functional behavioural analysis. One preliminary evaluation indicated a reduction in physical restraints at 12 months following program implementation, compared with a matched non-randomised control group (McCurdy & McIntyre, 2004).
Teaching Family model
The Teaching Family model is a well-known model of service delivery originally designed for juvenile offenders, but used for other children with behavioural issues. It is used and researched more extensively than other models of group care (James, 2011) and has formed the basis of many residential services in North America. A modified form of the model was used at Boys Town in Australia (Daly & Dowd, 1992). The model uses “teaching parents” to provide a family-like atmosphere to residential care. The teaching parents help children to learn positive social interaction and living skills. It is a competency-based skill development program, using clearly defined goals. The carers (or “teaching parents”) receive support and training as accredited and professionalised carer treatment teams.
Compared with non-matched “treatment as usual” residential care, this model of care has reported significant differences in academic attainment (Thompson et al., 1996), and observer ratings of parent–child treatment interactions and offending behaviour (Bedlington, Braukmann, Ramp, & Wolf, 1988).
Positive Peer Culture model
The Positive Peer Culture treatment model was developed by Vorrath and Brendtro (1985) and forms the basis for many residential programs in North America. It was specifically designed for “troubled and troubling” youth, in response to the need to deal with negative peer influences among offending youth (James, 2011). The key targeted outcome is the development of a socially motivated orientation of “care and concern” or social interest orientation. The culture conveys a belief in the capacity of youth to achieve. The focus is not on conforming to authority per se, but motivating this via responsibility for actions, reinforcement of prosocial behaviours and peer-helping. The aim is to foster a commitment to helping others, and hurtful behaviours are reduced as a by-product. The essential elements are assumed to be: the development of a norm of group belonging and responsibility (similar to the home environment); group meetings (problem-solving using a “common language” list of problem behaviours); use of community service learning (community service projects in the community); and teamwork focus (staff are organised in teams around distinct groups of children).
The evaluation of this model has been limited. One randomised control study demonstrated reduced recidivism and behavioural and social gains relative to control conditions (Leeman, Gibbs & Fuller, 1993). Reductions in unhelpful cognitive distortions and covert antisocial behaviour have also been found following this intervention (Nas, Brugman, & Koops, 2005).
For more detailed information about these programs, see James (2011).
Dr Sara McLean is a Research Fellow at the Australian Centre for Child Protection.
Rhys Price-Robertson is a Senior Research Officer (acting) at the Australian Institute of Family Studies.
Elly Robinson is a Senior Research Fellow (acting) at the Australian Institute of Family Studies.
The authors wish to acknowledge Dr Daryl Higgins for the initial conceptualisation and development of this Issues Paper. The authors also gratefully acknowledge the guidance and feedback provided by members of the National Therapeutic Residential Care Working Group.