For recovery and healing to occur in therapeutic residential care, there must be synergy or “congruence” between residential workers, the organisational culture and all other stakeholders in meeting the needs of the child or young person.  The work of James Anglin (2002), Sandra Bloom (2005) and Bruce Perry (2006) has been highly influential in space, arguing the need (at all levels) of service provision for a framework that provides a common language for organisational and worker–child relationships.

What follows is a coherent set of ideas that seeks to create synergy and a shared understanding of the critical role of relationship-based care in creating positive outcomes for young people.

Relationship-Based Care

It is almost a truism to say that everything in therapeutic residential care works better when relationships are healthy. However, since relationships permeate every aspect of therapeutic residential care this is absolutely the case. All aspects of residential care occur in the context of human relationships, which means all of the tasks underlying the provision of residential care work better when we tend to all relationships. This is particularly important because experiencing trauma can have a huge impact on interpersonal relationships, whereas engaging in meaningful relationships can mediate the destructive impact of trauma (e.g. Van der Kolk 2005). As Perry says (2008 p.116):

Healthy relationships are formed when residential staff (at all levels) consistently attune to one another, wonder with and about one another, follow the cues provided by one another, and hold one another with respect and dignity. We advance our relationship-based culture through the application of these relational and therapeutic practices to all relationships at all levels and in all disciplines.

Relational and Therapeutic Practices

The relational and therapeutic practices within therapeutic residential are integral to therapeutic healing and recovery and consists of:

Attuning – The practice of being present in the moment and tuning in to the young person or situation.

Curiosity – The practice of being genuinely interested in the young person. It requires an open-hearted curiosity about what can be learned about this unique individual, while intentionally suspending assumptions and judgement.

Following – The practice of listening to and focusing on what a young person is teaching us about what matters most to her or him and allowing that information to guide our interactions. It requires consciously suspending our own agenda.

Holding – The practice of intentionally creating a safe-haven to protect the safety and dignity of the young person.

Principles of Relationship Based Care

Relationship-based care is not only a philosophy and a way of being but also an operational blueprint that shapes positive residential caring behaviours that are sensitive and responsive to the trauma, attachment, loss and the developmental history of the child or young person.

The following six principles guide the transformation of infrastructure, processes, systems, and practices to support residential staff in creating therapeutic relationships with children and young people.

Within relationship-based care, there are three key relationships for the provision of humane and compassionate care. These relationships are the residential worker’s relationship with self, relationships with team members, and relationships with children and young people. This order does not signal priority, but rather acknowledges the importance of certain relationships dependency on others. Healthy, trusting relationships are dependent on how the individuals relate to themselves. Then, it follows that healthy relationships with children and young people are dependent on the relationships individuals have both with themselves and with their teams.

The following principles underpin a relationship based provision of therapeutic residential care:

Healing and Recovery Culture – The role of healing in therapeutic residential care is to challenge the traumatic relational blueprints of violence, abuse and neglect that the children and young people have internalised from their early life experiences so, that they can heal, develop and grow (Perry, 2006). As a result, these children and young people will be able to form and sustain positive and reciprocal relationships, and to be able to live inter-dependently within the community. Therapeutic relationships and a calming physical environment are core components of a healing and recovery culture.

Positive Leadership – Leadership is one of service. Servant leaders share power, put the needs of others first, and help people develop and perform as competently as possible (Colby Peters, 2018). Positive leadership is a key ingredient for leaders aspiring to advance a more positive healing culture. Inspired leaders who love what they do and the people with whom they do it, inspire others to greatness. Positive leadership is marked by deep affection and caring for those with whom we work and lead. Positivity in leadership means truly caring about each person, celebrating successes, as well as having empathy in times of struggle. It means being fully present in our interactions.

Teamwork – The provision of therapeutic residential care is a shared purpose. Working together with trust and mutual respect is essential (De Fazio, Thyer, Koehler, Hains-Wesson, & Tsindos, 2013). Effective therapeutic residential care requires a consistent and coordinated approach through a unified therapeutic plan and information sharing amongst Care Team members and other services and professionals.

Inter-professional Practice – Therapeutic residential care is underpinned by a recognition of the importance of specialist supports, healthy relationships and good communication between all stakeholders. The different perspectives of people in multiple disciplines are essential to effective collaboration and optimal care and outcomes of children and young people in OOHC (Anglin, 2002). The Care Team approach allows for all practitioners and service systems to bring their best wisdom to the interdisciplinary group. The Care Team follows a formula of Responsibility + Authority + Accountability to facilitate greater personal ownership and alignment with and among Care Team members.

Therapeutic Care Delivery – Residential staff members need to know the child or young person as an individual, understand their needs, identity, attachment and heritage to provide care based on what is most important to the child and young person. While at the same time providing a safe, predictable environment in which the child or young person is protected from re-traumatising experiences (Bloom, 2005).

In the provision of therapeutic care there is a continuous focus on the following 3 rules:

1. Hold the child and young person at the centre of care
2. Make the best way the easiest way
3. Support all relationships

Designing and delivering a service system using these simple rules actively promotes the conditions for therapeutic care that is safe, effective, child-centered, timely, efficient and equitable.

System design – The continuous quality improvement of structures, processes, and relationships to bring quality, safety, effectiveness and efficiency to the residential care experience and the work environment is essential and goes beyond mere compliance with standards; it involves ongoing learning and improvement of services (Parenting Research Centre, 2015). The aim of improvements should be to allow staff and managers to focus on what is most important, safe and efficient. Any change should have had the benefit of a rigorous, humble and curious approach.

Conclusion

Relationship-based care is a core set of principles and values that come together to create a culture in which the residential worker – young person relationship is held as sacred and every policy, process, practice, and behaviour functions to strengthen this relationship. Bruce Perry (2008) invites us to consider:

To successfully implement a transition from a culture of practical tasks and provision of basic care to a culture of therapeutic care with the residential worker-young person relationship as the cornerstone, the service needs leadership support and attention on an ongoing basis.

Focusing on the relationship between the residential worker and the young person places the child’s needs first. Building teamwork and improved communication between the leadership team and staff is fostering transparency and respect. Joy and meaning in work come from being able to spend time listening and learning about what matters most to children and young people, and then being able to act on what is learned. While cultural transformation takes years, a relationship-based model provides the common purpose, language, and infrastructure to drive the transition forward.

Noel MacNamara
Senior Advisor, Centre for Excellence in Therapeutic Care

References

Anglin, J. (2002). Pain, normality and the struggle for congruence: Reinterpreting residential care for children and youth. Birmingham, NY: Haworth Press.

Bloom, S. L. (2005). Creating sanctuary for kids: helping children to heal from violence. Therapeutic Community: The International Journal for Therapeutic and Supportive Organizations, 26(1), 57–63.

 Colby Peters, S. (2018) Defining social work leadership: a theoretical and conceptual review and analysis, Journal of Social Work Practice, 32:1, 31-44.

 De Fazio, T., Thyer, E., Koehler, N., Hains-Wesson, R., & Tsindos, S. (2013). Teamwork. Deakin Learning Futures, Deakin University.

Parenting Research Centre (2015). The NSW statutory out-of-home care: Quality Assurance Framework report was commissioned by the New South Wales Department of Family and Community Services (FACS). Melbourne University.

Perry, B. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children: The neurosequential model of therapeutics. In. N Boyd Webb (ed). Working with traumatized children in youth and child welfare. New York: Guilford Press (pp. 27–52).

Bruce, P., & Szalavitz, M. (2008). The Boy Who Was Raised As a Dog: And Other Stories from a Child Psychiatrist’s Notebook: What Traumatized Children Can Teach Us About Loss, Love, and Healing. New York: Basic Books.

Priebe S., & McCabe R. (2008). Therapeutic relationships in psychiatry: the basis of therapy or therapy in itself? International Review of Psychiatry, 20: 521–6.

Van der Kolk, B. (2005) Developmental trauma disorder: towards a rational diagnosis for chronically traumatized children. Psychiatric Annals, 35: 401–8.