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Family placement—a hopeful alternative
10urnal of Adolescence 1978, x, 363-369
Family placement-a hopeful alternative* NANCY HAZELt This paper is not about preventive, community-based services which help to maintain adolescents in their own homes, but about placement, i.e, the care of those who cannot remain at home. Before describing our work in Kent, however, let us look briefly at the question "Alternative to what?" As England uses family placements for only a minute proportion of children who enter public care as adolescents, we obviously believe in the other alternative, namely residential care. Although a small proportion of adolescents in care enter specialist adolescent units, the main body are cared for in various types of community homes-assessment centres, Community Homes with Education on the premises, i.e. the direct descendants of the approved schools, and a mixed bag of other establishments. Our placement policy follows shifts in our beliefs. In the 1950's we believed in specialized services. Approved schools catered for one sex, one type of symptom-delinquency-and further developed themselves to cater for younger, backward boys, older boys of different types, etc. 'Ve then became aware that a specialist system sent the adolescents to far-distant places, ignoring links with their home and their local culture. Regional Planning sought to ensure a degree of localization at the cost of less specialization. Then came the notorious Children's (1969) Act-the deprived and depraved were to become one category and approved schools and children's homes all became community homes. But, did this change anything except the labels? The changes do not seem to be quite what we expected. Pat Cawson's national survey carried out for the D.H.S.S. in 1977 (Cawson, 1977) shows that the present generation of care order children is younger and less delinquent than the pre-1971 approved school generation. Many are committed at their first Court appearance, and most of them are placed in residential care immediately after the care order. Fostering is practicaIly never considered. These children, mostly adolescents, often spent many months in assessment centres and then proceeded to community homes with • This paper was given at the 13th A.P.S.A. Conference held at Lancaster University in 1978.
t University of Kent, and Kent County Council, Social Services Department, Canterbury. Kent. @ 1978 The Association for the Psychi.tric Study of Adoleocenls
364
NANCY HAZEL
education on the premises. Whilst in residential care their rate of offending was high. However, of those placed home-on-trial rather few offended. Many people will already be familiar with Clarke and Cornish's (1975) follow-up study of Kingswood boys. They compared two regimes, a conventional structured regime and a therapeutic community regime. The reconviction rates over three years for both regimes were 67 per cent for those released on after care and 75 per cent if all releases are included. The authors suggest that "only for about 20 per cent of those admitted to the school could it be argued that institutional intervention had provided more than a temporary interruption of their delinquent behaviour." So practice is firmly wedded to residential care for the majority of adolescents who cannot remain in their own homes. On the whole the principle of placing like with like is followed. Delinquent boys with other delinquent boys, disturbed girls with other disturbed girls, etc. These beliefs are maintained in the face of mounting evidence that our very costly system of residential care is counter-productive. Some other European countries share our belief in residential treatment. For example Belgium has a very low rate of fostering. It is believed that standards can more easily be maintained in large establishments than in scattered family homes. It is also believed that caring for damaged children is a task for experts rather than lay people. A large establishment can employ an array of experts: psychiatrists, psychologists, social workers, teachers, speech therapists, remedial gymnasts, pediatricians and others . The child will be seen by these experts who will discuss their findings at frequent case conferences. There is no research to indicate that this very expensive system is successful. Other European countries do not share these beliefs, and possibly Sweden has moved furthest from the residential care model. In 1974 a Swedish Royal Commission on the Placement of Children and Young Persons found that about 70 per cent of children in care up to 15 years of age lived in foster homes. Adolescents in care also tended to live in foster homes or small private arrangements, bringing the total up to a very high figure. Even the national youth welfare schools, which catered for the older, most delinquent adolescents, quickly moved their inmates out into foster homes, with the possibility of recall if necessary. The Royal Commission came out clearly in favour of maintenance in the community, either at home or in foster care and set out four principles which I find are a valuable set of guidelines for any placement. The principles are: I.
Normalization
the right to live a normal life in the community, using the normal services--schools, health care, etc.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE 2. Localization 3. Voluntariness 4. Participation
365
the right not to be uprooted from one's home area the right not to be subjcctcd to co-ercion the right to be consulted.
A national experiment is now being carried out in southern Sweden systematically to develop these principles. The next step there will be the closure of the Youth Prisons. They now have only about 200 inmates and their failure rate is high. This is a different kind of thinking from ours. Studies of placement in North-Western European countries suggest that it is possible to have almost any kind of placement system provided you believe in it. The determinants do not appear to be wealth, population etc., but rather fundamental beliefs. So what do we believe in the Kent Project? We believe that lay people, working in their own homes can carry out many of the tasks traditionally assigned to experts. We believe in the opposite of like-with-like placement, i.e., we think that one delinquent or disturbed adolescent placed in a normal family is more likely to change than one placed in a residential group of other disturbed or delinquent adolescents. We believe that this kind of foster care should be well paid and recognized as equal in esteem and status to social work. The Project was set up in January 1975 as a 5-year demonstration, backed by the University of Kent, partly funded by the Gatsby Charitable Foundation, placing adolescents in the care of Kent County Council, which pays the placement costs. In the first progress report (1976) the objectives of the Project were defined as follows: "an attempt to test the long-held view that a large proportion of English children are 'unsuitable for fostering'. More specifically, what we want to know is: if you spend as much money on developing a family placement in the community as it costs to use a residential place, can you obtain more effective help for the adolescent with severe problems who must, unavoidably, leave his home, at any rate for a short period?" The Project set out to place the most "difficult" group, which was defined as adolescents aged 14 to 17 with "severe problems". This age group is, of course, also a peak age of entry into care. It was hoped that a "methods package" could be developed which could be replicated elsewhere. THE "METHODS PACKAGE" The essential components of this package were: (1) The concept of foster care as work for which a fee is paid. One placement is estimated as equivalent to a part-time job and two placements constitute a full-time job. We now know that three placements can be
NANCY HAZEL
possible if built up to. In 1978 the fee (taxable) was £37.50 and in addition the tax-free boarding-out allowance was paid (£10-£12 per week). (2) The group as the focus of work. All Project parents attend the groups
which meet every 2-3 weeks and have a number of functions: (a) Self and group selection. By entering the group applicants learn to understand what is expected of them and either become part of the group or are helped to leave it. (b) Preparation for placement. The group helps applicants to think through their futurerole and provides appropriate information. (c) A network for support and transfer. The group offers support both formally and informally. It is also possible for adolescents to transfer from one family to another in case of need, and they appear to accept these moves "within the tribe". The mature groups can now manage almost all crises themselves, without asking for a social worker's help. (d) The development of policy. Issues relating to present and future practice, financial matters, etc., are discussed and decided, or recommendations made in the groups. (3) Placements are for treatment, i.e. to promote change rather than to provide a substitute home. The placements are essentially: (a) Time-limited. A plan is made for the next piece of time-"until you leave school"-or any other convenient period. This can, of course, be reconsidered, shortened or extended. (b) Problem-solving. The objective of the" placement is to deal with problems which the adolescent can identify. They are usually fairly simple to state, such as going to school or not running away, but sometimes more complicated, such as learning to form better relationships with adults or peers. The objectives of the placement are written down in a brief contract for the adolescent and the foster family. The family of origin may also agree to specific tasks, but .t his contract has not so far been written. The Project and Divisional social workers also have brief agreements which divide the work between them. The general principle is that it is the responsibility of the Project worker to recruit and prepare the families, and to make the match and set the placement going. Long-term maintenance should, as far as possible, be carried out by the Divisional social worker. The Project worker has the ongoing task "of working with the foster parents and will act as trouble shooter when extra help is needed.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE
367
(4) Use of publicity. We believe that it is essential for the general public to understand what we are trying to do, if we want people to volunteer to help us. The Project started with a press conference and has succeeded in retaining the interest of the media. Project staff, foster parents and adolescents have spoken to reporters, broadcast and appeared on television. The parents of origin do not object to this publicityindeed why should these boys and girls in placement feel stigmatized in any way? As a result of this publicity there have been no difficulties in recruitment so far. The Project expects the family to undertake all work with the adolescents and very often to work directly with the family of origin. This means taking over some of the work traditionally done by social workers. It has not always been easy for field social workers and Project families to develop a satisfactory working relationship. The problems are similar to those in the relationship between field and residential staff-both sides may easily become possessive and defensive. In addition social workers are not accustomed to seeing foster parents as of equal status to themselves and the families sometimes perceive them as condescending. Our experience is that the "methods package" seems to work well. The concept of a "caring career at home" attracts families where the wife has had satisfying experiences of paid employment and now wishes to have the financial rewards, intellectual stimulation and social contacts of work without leaving her home, and where the husband and wife enjoy having a shared task. However the concept of equality of status with social workers is crucial. Difficulties presented by the adolescents can generally, but not always, be overcome by patient and persistent work. In the first three years of the Project, rejection of an adolescent because of unacceptable behaviour is almost unknown. Placements have been terminated by mutual agreement where it was felt that no further progress was possible, or where the police intervened-the most frequent cause of breakdown, or very rarely, where the adolescent refused to stay. Absconding is much lower than in residential care. Any scheme which places disturbed and delinquent adolescents in the community needs an effective back-up service for crises. This has been difficult in Kent. About once a year, an adolescent "blows up" virtually without warning and usually violently. We need a safe place for a short period until we can see what to do next-and the safe place must be able to provide talking-down and access to psychiatric help. By I July 1978 we had made 100 placements with.approximately equal numbers of boys and girls. Excluding a few who failed to settle within the first 8 weeks, eight boys failed, in that the placement was prematurely
368
NANCY HAZEL
concluded by admission to residential care (including Borstal and Detention Centre). All other placements, ongoing or completed, had varying degrees of success. A subjective evaluation by the Project team showed that !ths of the current placements appeared to be doing well or very well, and in fth of the cases there were some problems. Dr Yelloly, Head of Social 'York Courses at Goldsmith College, is undertaking an independent evaluation and has studied 25 consecutive placements made in the early period of the Project. The evaluation is not yet complete but suggests that 17 boys and girls improved in placement, four remained unchanged or marginally worse, the remaining four are not yet classified. This is a surprisingly high success rate. 'How much lasting improvement placements make to the adolescent's ability to survive in society in the long run is impossible to say. It may be that follow-up results are no better than residential care. Even if this were so, family placement is still cheaper and more humane than institutional care for delinquents and does not appear to involve any greater risks to the community. But we must evaluate our work as far as we can and we should like to complete:
(I) The "in-placement" evaluation of 25 consecutive cases; (2) an evaluation of all placements; (3) a 3-year follow-up; (4) a costing study. What we do know is that the Kassel project in Germany, which is very much like ours but a little older, has made 200 placements and completed an evaluation about which they are very optimistic. One very important part of the Project's ideology is that we reject "expert dominance". The foster parents are our equal partners and recommendations on policy are made by an Advisory committee composed of equal numbers of foster parents (one representative from each of the six groups) and senior members of the Department. It is essential that the work of this Committee should continue to develop. The experimental period ends in December 1979, the next step is integration into the Department. It has now been agreed that Kent will be divided into three areas under three assistant directors, to provide an administrative tier above the IS divisions. It is recommended that the Project should de-centralize to the areas, as it is too small to provide groups in IS divisions, and too specialized to obtain enough referrals within their limited population. It is felt that areas will provide convenient catchment grounds for referrals and allow sufficient space to choose between "near home" or "fresh start" placements. The need for specialist staff to run the Project is accepted without question.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE
369
The work with adolescents in Kent was a deliberate attempt to import foreign models-in particular the Swedish thinking about maintenance in the community and from America the Read and Epstein task-centred approach, with specific goals and time limits. \Ve believe that it is essential to set out a clear theoretical model before embarking on any demonstration project. \Ve have done this and we believe that our methods work.
REFERENCES Cawson, P. (J978). Young Offenders in Care. D .H.S.S. Social Research Branch. Clarke, R. V. G. and Cornish, D. B. (J975). Residential Treatment and Its Effects on Delinquency, London: H.M.S.a.
Family placement-a hopeful alternative* NANCY HAZELt This paper is not about preventive, community-based services which help to maintain adolescents in their own homes, but about placement, i.e, the care of those who cannot remain at home. Before describing our work in Kent, however, let us look briefly at the question "Alternative to what?" As England uses family placements for only a minute proportion of children who enter public care as adolescents, we obviously believe in the other alternative, namely residential care. Although a small proportion of adolescents in care enter specialist adolescent units, the main body are cared for in various types of community homes-assessment centres, Community Homes with Education on the premises, i.e. the direct descendants of the approved schools, and a mixed bag of other establishments. Our placement policy follows shifts in our beliefs. In the 1950's we believed in specialized services. Approved schools catered for one sex, one type of symptom-delinquency-and further developed themselves to cater for younger, backward boys, older boys of different types, etc. 'Ve then became aware that a specialist system sent the adolescents to far-distant places, ignoring links with their home and their local culture. Regional Planning sought to ensure a degree of localization at the cost of less specialization. Then came the notorious Children's (1969) Act-the deprived and depraved were to become one category and approved schools and children's homes all became community homes. But, did this change anything except the labels? The changes do not seem to be quite what we expected. Pat Cawson's national survey carried out for the D.H.S.S. in 1977 (Cawson, 1977) shows that the present generation of care order children is younger and less delinquent than the pre-1971 approved school generation. Many are committed at their first Court appearance, and most of them are placed in residential care immediately after the care order. Fostering is practicaIly never considered. These children, mostly adolescents, often spent many months in assessment centres and then proceeded to community homes with • This paper was given at the 13th A.P.S.A. Conference held at Lancaster University in 1978.
t University of Kent, and Kent County Council, Social Services Department, Canterbury. Kent. @ 1978 The Association for the Psychi.tric Study of Adoleocenls
364
NANCY HAZEL
education on the premises. Whilst in residential care their rate of offending was high. However, of those placed home-on-trial rather few offended. Many people will already be familiar with Clarke and Cornish's (1975) follow-up study of Kingswood boys. They compared two regimes, a conventional structured regime and a therapeutic community regime. The reconviction rates over three years for both regimes were 67 per cent for those released on after care and 75 per cent if all releases are included. The authors suggest that "only for about 20 per cent of those admitted to the school could it be argued that institutional intervention had provided more than a temporary interruption of their delinquent behaviour." So practice is firmly wedded to residential care for the majority of adolescents who cannot remain in their own homes. On the whole the principle of placing like with like is followed. Delinquent boys with other delinquent boys, disturbed girls with other disturbed girls, etc. These beliefs are maintained in the face of mounting evidence that our very costly system of residential care is counter-productive. Some other European countries share our belief in residential treatment. For example Belgium has a very low rate of fostering. It is believed that standards can more easily be maintained in large establishments than in scattered family homes. It is also believed that caring for damaged children is a task for experts rather than lay people. A large establishment can employ an array of experts: psychiatrists, psychologists, social workers, teachers, speech therapists, remedial gymnasts, pediatricians and others . The child will be seen by these experts who will discuss their findings at frequent case conferences. There is no research to indicate that this very expensive system is successful. Other European countries do not share these beliefs, and possibly Sweden has moved furthest from the residential care model. In 1974 a Swedish Royal Commission on the Placement of Children and Young Persons found that about 70 per cent of children in care up to 15 years of age lived in foster homes. Adolescents in care also tended to live in foster homes or small private arrangements, bringing the total up to a very high figure. Even the national youth welfare schools, which catered for the older, most delinquent adolescents, quickly moved their inmates out into foster homes, with the possibility of recall if necessary. The Royal Commission came out clearly in favour of maintenance in the community, either at home or in foster care and set out four principles which I find are a valuable set of guidelines for any placement. The principles are: I.
Normalization
the right to live a normal life in the community, using the normal services--schools, health care, etc.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE 2. Localization 3. Voluntariness 4. Participation
365
the right not to be uprooted from one's home area the right not to be subjcctcd to co-ercion the right to be consulted.
A national experiment is now being carried out in southern Sweden systematically to develop these principles. The next step there will be the closure of the Youth Prisons. They now have only about 200 inmates and their failure rate is high. This is a different kind of thinking from ours. Studies of placement in North-Western European countries suggest that it is possible to have almost any kind of placement system provided you believe in it. The determinants do not appear to be wealth, population etc., but rather fundamental beliefs. So what do we believe in the Kent Project? We believe that lay people, working in their own homes can carry out many of the tasks traditionally assigned to experts. We believe in the opposite of like-with-like placement, i.e., we think that one delinquent or disturbed adolescent placed in a normal family is more likely to change than one placed in a residential group of other disturbed or delinquent adolescents. We believe that this kind of foster care should be well paid and recognized as equal in esteem and status to social work. The Project was set up in January 1975 as a 5-year demonstration, backed by the University of Kent, partly funded by the Gatsby Charitable Foundation, placing adolescents in the care of Kent County Council, which pays the placement costs. In the first progress report (1976) the objectives of the Project were defined as follows: "an attempt to test the long-held view that a large proportion of English children are 'unsuitable for fostering'. More specifically, what we want to know is: if you spend as much money on developing a family placement in the community as it costs to use a residential place, can you obtain more effective help for the adolescent with severe problems who must, unavoidably, leave his home, at any rate for a short period?" The Project set out to place the most "difficult" group, which was defined as adolescents aged 14 to 17 with "severe problems". This age group is, of course, also a peak age of entry into care. It was hoped that a "methods package" could be developed which could be replicated elsewhere. THE "METHODS PACKAGE" The essential components of this package were: (1) The concept of foster care as work for which a fee is paid. One placement is estimated as equivalent to a part-time job and two placements constitute a full-time job. We now know that three placements can be
NANCY HAZEL
possible if built up to. In 1978 the fee (taxable) was £37.50 and in addition the tax-free boarding-out allowance was paid (£10-£12 per week). (2) The group as the focus of work. All Project parents attend the groups
which meet every 2-3 weeks and have a number of functions: (a) Self and group selection. By entering the group applicants learn to understand what is expected of them and either become part of the group or are helped to leave it. (b) Preparation for placement. The group helps applicants to think through their futurerole and provides appropriate information. (c) A network for support and transfer. The group offers support both formally and informally. It is also possible for adolescents to transfer from one family to another in case of need, and they appear to accept these moves "within the tribe". The mature groups can now manage almost all crises themselves, without asking for a social worker's help. (d) The development of policy. Issues relating to present and future practice, financial matters, etc., are discussed and decided, or recommendations made in the groups. (3) Placements are for treatment, i.e. to promote change rather than to provide a substitute home. The placements are essentially: (a) Time-limited. A plan is made for the next piece of time-"until you leave school"-or any other convenient period. This can, of course, be reconsidered, shortened or extended. (b) Problem-solving. The objective of the" placement is to deal with problems which the adolescent can identify. They are usually fairly simple to state, such as going to school or not running away, but sometimes more complicated, such as learning to form better relationships with adults or peers. The objectives of the placement are written down in a brief contract for the adolescent and the foster family. The family of origin may also agree to specific tasks, but .t his contract has not so far been written. The Project and Divisional social workers also have brief agreements which divide the work between them. The general principle is that it is the responsibility of the Project worker to recruit and prepare the families, and to make the match and set the placement going. Long-term maintenance should, as far as possible, be carried out by the Divisional social worker. The Project worker has the ongoing task "of working with the foster parents and will act as trouble shooter when extra help is needed.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE
367
(4) Use of publicity. We believe that it is essential for the general public to understand what we are trying to do, if we want people to volunteer to help us. The Project started with a press conference and has succeeded in retaining the interest of the media. Project staff, foster parents and adolescents have spoken to reporters, broadcast and appeared on television. The parents of origin do not object to this publicityindeed why should these boys and girls in placement feel stigmatized in any way? As a result of this publicity there have been no difficulties in recruitment so far. The Project expects the family to undertake all work with the adolescents and very often to work directly with the family of origin. This means taking over some of the work traditionally done by social workers. It has not always been easy for field social workers and Project families to develop a satisfactory working relationship. The problems are similar to those in the relationship between field and residential staff-both sides may easily become possessive and defensive. In addition social workers are not accustomed to seeing foster parents as of equal status to themselves and the families sometimes perceive them as condescending. Our experience is that the "methods package" seems to work well. The concept of a "caring career at home" attracts families where the wife has had satisfying experiences of paid employment and now wishes to have the financial rewards, intellectual stimulation and social contacts of work without leaving her home, and where the husband and wife enjoy having a shared task. However the concept of equality of status with social workers is crucial. Difficulties presented by the adolescents can generally, but not always, be overcome by patient and persistent work. In the first three years of the Project, rejection of an adolescent because of unacceptable behaviour is almost unknown. Placements have been terminated by mutual agreement where it was felt that no further progress was possible, or where the police intervened-the most frequent cause of breakdown, or very rarely, where the adolescent refused to stay. Absconding is much lower than in residential care. Any scheme which places disturbed and delinquent adolescents in the community needs an effective back-up service for crises. This has been difficult in Kent. About once a year, an adolescent "blows up" virtually without warning and usually violently. We need a safe place for a short period until we can see what to do next-and the safe place must be able to provide talking-down and access to psychiatric help. By I July 1978 we had made 100 placements with.approximately equal numbers of boys and girls. Excluding a few who failed to settle within the first 8 weeks, eight boys failed, in that the placement was prematurely
368
NANCY HAZEL
concluded by admission to residential care (including Borstal and Detention Centre). All other placements, ongoing or completed, had varying degrees of success. A subjective evaluation by the Project team showed that !ths of the current placements appeared to be doing well or very well, and in fth of the cases there were some problems. Dr Yelloly, Head of Social 'York Courses at Goldsmith College, is undertaking an independent evaluation and has studied 25 consecutive placements made in the early period of the Project. The evaluation is not yet complete but suggests that 17 boys and girls improved in placement, four remained unchanged or marginally worse, the remaining four are not yet classified. This is a surprisingly high success rate. 'How much lasting improvement placements make to the adolescent's ability to survive in society in the long run is impossible to say. It may be that follow-up results are no better than residential care. Even if this were so, family placement is still cheaper and more humane than institutional care for delinquents and does not appear to involve any greater risks to the community. But we must evaluate our work as far as we can and we should like to complete:
(I) The "in-placement" evaluation of 25 consecutive cases; (2) an evaluation of all placements; (3) a 3-year follow-up; (4) a costing study. What we do know is that the Kassel project in Germany, which is very much like ours but a little older, has made 200 placements and completed an evaluation about which they are very optimistic. One very important part of the Project's ideology is that we reject "expert dominance". The foster parents are our equal partners and recommendations on policy are made by an Advisory committee composed of equal numbers of foster parents (one representative from each of the six groups) and senior members of the Department. It is essential that the work of this Committee should continue to develop. The experimental period ends in December 1979, the next step is integration into the Department. It has now been agreed that Kent will be divided into three areas under three assistant directors, to provide an administrative tier above the IS divisions. It is recommended that the Project should de-centralize to the areas, as it is too small to provide groups in IS divisions, and too specialized to obtain enough referrals within their limited population. It is felt that areas will provide convenient catchment grounds for referrals and allow sufficient space to choose between "near home" or "fresh start" placements. The need for specialist staff to run the Project is accepted without question.
FAMILY PLACEMENT-A HOPEFUL ALTERNATIVE
369
The work with adolescents in Kent was a deliberate attempt to import foreign models-in particular the Swedish thinking about maintenance in the community and from America the Read and Epstein task-centred approach, with specific goals and time limits. \Ve believe that it is essential to set out a clear theoretical model before embarking on any demonstration project. \Ve have done this and we believe that our methods work.
REFERENCES Cawson, P. (J978). Young Offenders in Care. D .H.S.S. Social Research Branch. Clarke, R. V. G. and Cornish, D. B. (J975). Residential Treatment and Its Effects on Delinquency, London: H.M.S.a.