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Outcomes of therapeutic residential work?

2015

Hi All,

I’m working on a project to identify the outcomes of therapeutic residential work with young people. I’m wondering what assessment frameworks are used to assess young people’s change and growth in your organisations. Is anyone using a tool for assessing outcomes that they really like? Any good resources on the subject?

A related interest is the benefits and pitfalls of outcomes focused work with young people. Would you say that basing our work on identified outcomes improves the quality of our work, or does it reduce it to a mathematical exercise? Any articles or opinions on the subject are welcome.

Many thanks,

Wesley Sensenig
Co Waterford, Ireland
...

Hi Wesley,

I think you know the answer. As I look back on my long career of interfering in mainly poor people’s lives I feel I can say with certainty that assessment tools and the measuring of outcomes are only necessary to play the new managerial game of chasing money in the so desirable mixed economy of care. It allows private contractors such as G4S and Serco, with their slick bidding and manipulation of stats, to make profit out of people’s misery.

It means that small projects staffed by passionate and inspiring people who truly turn people’s lives around through the power of relationships based on compassion, solidarity and love struggle hand to mouth on 3-5 year funding cycles with valuable time used up in measuring pointless stuff and writing it up in a glossy manner only to find that their service gets cut anyway.

It means that the social policy focus looks at individual deficit and how it is ameliorated or not by innovative interventions when everyone knows that the majority of the young people, families and communities we work with require structural change to address the poverty, institutionalised racism and class war perpetrated by the ruling elites.

It is hard to speak up in the face of this oppression because when you speak the language of love and compassion it evokes dissonance in the apparatchiks who have wedded themselves and their careers to the new managerial paradigm. They distance themselves from feeling by asking you to measure, implement, report and provide evidence. This feeds into the evidence base that tells them their professional lives aren’t a lie and that they aren’t part of the problem.

I meet many individuals who have struggled at points in their lives and those who lived before the outcomes era never say ‘I wish there had been an evidenced based approach when I had difficulties that would have improved my situation’ and those post outcomes never say that an evidenced based programme saved my life, often they have little awareness of the programme. What they all say is ‘if it wasn’t for so and so being there, understanding, fighting my corner, giving me that book, music, experience I might not be here today’.

This old punk signs off with a quote from the Little Prince: ‘It is only with the heart that one can see rightly; what is essential is invisible to the eye.’ (Antoine de Saint-Exupery)

Peace,

Jeremy Millar
...

Hi Wesley

When I was working in residential care we utilized developmental plans to assess where an individual is, co-created strategies to assist an individual reach goals, we would review at team meetings how the strategies are working and then finally for the paper work (3 months) we would assess what worked what didn't. These developmental plans were altered accordingly with the consultation of youth/families/social services.

Charlene Pickrem
...

Hi Wesley,

Broadly speaking I think that outcomes based work is a good thing because it brings focus and accountability to the work.

The challenge though, is to define 'reasonable outcomes' and to identify whose agenda takes priority in the process. In adult therapy the client sets the agenda and the therapist facilitates the process of achieving whatever the client wants to achieve. In residential child care however, there is the child, his birth family, his multidisciplinary team, the state and the taxpayer (who is funding the whole process) all of whom have a vested interest in setting the agenda for the work with the child and all of whom may have different ideas about what the work should be.

If the child's wants and needs can be identified and given priority over the rest of the aforementioned potentially competing vested interests, I say go for it, but remember that sometimes the most beneficial outcomes from our work may not be seen for 20 years or more so while definable goals may keep the funding agencies happy, they are not necessarily the most reliable indicator of effective therapeutic work!!!

With very best wishes,

John Byrne
(Also in Ireland, though it feels like Spain today)
...

Interesting topic. I want to propose that therapeutic work in its entirety requires a response that is embedded in the values of the organisation offering the service. One can easily obtain measuring instruments and it only then becomes an exercise that is not supported by the organisation. Therefore I will stand by the fact the environment should first be developed to enhance therapeutic work before an instrument is developed.

In the agency where I worked our assessment of children was used to determined the type of therapy that a child will require and then attempts are made to offer the best service.

Alfred
...

Wesley,

Here in Louisiana, the outcome measure I’ve seen most often used was ‘remained out of institutional care after discharge,’ usually based on a one-year follow-up.

The measure I like, ‘Still in school, completed school, or employed,’ based on a five-year follow-up.

John Stein
New Orleans
...

Hi Wes,

I'm no longer involved in residential work with kids but, from 1970 to 1993, I was the Director of a large privately operated residential facility in Western Canada. As we had our own research department we were able to get into the program evaluation business earlier than most.

When the 'outcome' /accountability movement became popular in the 1980's we began by taking a look at what the 'system' really wanted from its residential programs. In a nutshell, it wanted 'problem' kids to be removed from their homes and returned to their families, schools and communities as compliant contributors to the status quo.

Well, the first part was easy, even if it meant resorting to methods of restraint and confinement. The second was more problematic. It wasn't sufficient to simply demonstrate that the desired changes had taken place in course of 'treatment' - they wanted to be assured that these gains would be sustained once the 'deviants' had been slotted back into the family, school and community family, school and community systems in which the 'problems' had been created.

Apart from rejecting this mandate from the get-go, it was clear to us that if we bought into this expectation, we would be setting ourselves up for failure. We were fortunate to have a substantial private endowment so we didn't have to impress public funding sources with unattainable goals and mathematical outcome measures. Based upon a treatment model that integrated behavioural, cognitive, emotional and relational processes, we used our existing research base, to establish the following five objectives:

1. To assist our residents in examining and modifying those patterns of behaviour that prevented them from establishing and sustaining effective personal relationships. In those days, behaviour modification was all the rage and, when you have complete control of the environment, this is a relatively simple task. But we wanted to encourage change from the 'inside-out' rather than through the simple application of external rewards, deprivation and punishment. In other words, we wanted to bring the resident's sense of Self into the equation through interpersonal relationships. For assessment purposes, we combined behaviour rating scales with a number of self awareness and self-concept inventories.

2. To assist our residents in developing a sense of self-determination and personal responsibility. Based upon the belief that all kids have the inner resources to create their own lives in their own way, we encouraged our residents to discover these inner potentials and take responsibility for their own decisions rather than simply conform to external expectations. To assess progress we used a 'locus of control' inventory devised by our research team.

3. To assist our residents in enhancing their own self-esteem through self-evaluations, rather than relying upon the appraisals of others. This was primarily a relational strategy that invited residents to explore and express their inner experiences. The basic task of the counsellor was to "mirror" that experience accurately with no other agenda. We used a combination of self-esteem protocols to measure these 'outcomes'.

4. To assist our residents in developing relationships based upon mutual respect and understanding while retaining a solid sense of Self. This involved considerable work with personal boundaries and role-taking ability. Much of the collected data was based upon the subjective reports of both resident and counsellor but we did use a social perspective-taking scale to add a few numbers for 'research' purposes.

5. To assist our residents in transferring their learning into their post-residential placements. We would begin this work as soon as possible after admission to our residential program. In many cases, conjoint family therapy was an essential ingredient but the overall task was to work with whatever the social system happened to be. We were fortunate to have the necessary resources to offer post-discharge support as needed.

So, the big question remains - were we "successful"? Well, based upon the goals we set, the questions we asked and the data we collected, we were more than satisfied with the 'outcomes'. Were the gains made through the residential program sustained after discharge? Again, follow-up studies at six and twelve months were very encouraging. So, did all these kids go on to lead lives of happiness and self-fulfillment? Of course not, but we began by insisting that we would not take that responsibility away from the kids their caretakers and the community at large.

Well Wes, that's a lengthy response to your question but there's much more I could say. The nature of residential 'treatment' has changed over the years and it seems to me that many programs are now designed to diagnose and classify specific disorders. In this case the whole nature of establishing goals and measuring outcomes has changed also.

I hope these skimpy reflections of an old-timer may help you to address your well-timed question. Let me know if you'd like more information and I'll dig it out of the archives – just for the hell of it.

Cheers,

Gerry Fewster

Hi, Wesley,

We have a researcher here next week who is working on a systematic literature review, examining the evidence for democratic therapeutic communities. This is part of her work in the Trent Clinical Psychology Doctorate course, and is intended to update the work of Lees, Manning and Rawlings in their 1999 "Therapeutic community effectiveness: a systematic international review..."

Lees/Manning/Rawlings looked at research relating to people with personality disorders and mentally disordered offenders, but Georgina may be looking more widely (given her project title), and may also be a useful contact generally.

Best wishes,

Craig Fees
...

Hi Wes,

In Australia when 11 therapeutic pilots were introduced, a concurrent review of outcomes was commissioned at the same time. This was a fantastic review and might be helpful for you. It was completed by Verso Consulting and is available on the web - if you google Evaluation of therapeutic residential care pilot programs, you will find it. If anything in the Australian context needs further information please contact me.

Good luck.

Regards
Glenys Bristow

P.S. Also wanted to congratulate Gerry on his amazing response which I found really helpful - loved it. Thank you!

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