5. Care

SIX FACETS - Care Highlighted

When we speak of care, we generally think about doing things for people, not with them—but by involving people and their families in having more voice and choice in the process of care, we achieve better outcomes.

At the heart of a new reality in care is decentralized power and participatory decision-making. To illustrate care in a new reality, I highlight a number of programs and working models in several countries:

  • Family Group Conference (FGC) is a process, instituted in 1989 by the government of New Zealand, in which families are engaged in solving their own problems, as an alternative to government intervention.
  • Eigen Kracht Centrale is a Dutch social service agency that provides FGCs throughout the Netherlands.
  • Daybreak Family Group Conferences is an FGC service provider in the United Kingdom.
  • Community Service Foundation and Buxmont Academy are American non-profit organizations that my wife, Susan, and I founded. CSF and Buxmont pioneered the use of restorative practices in education, counseling and residential programs for delinquent and at-risk youth and their families in southeastern Pennsylvania.
  • Stockholm City Mission uses restorative practices effectively in its homeless shelters, engaging clients in addressing their own behavior problems, instead of responding with staff-imposed punishment that usually excludes clients from the shelter for a period of time.
  • The Sanctuary Model is an effective blueprint for clinical and organizational change that trains staff and patients or clients in a wide range of settings to create a participatory, mutually supportive, “trauma-informed” therapeutic community.
  • Oranjehuis is a Belgian agency that employs restorative practices across all of its youth services, including its innovative new “Columbus” project, which has reduced waiting lists for counseling services by involving young people and their families in achieving their own “positive reorientation.”

The System Versus the Lifeworld

Historian Yuval Noah Harari explains that throughout most of human history, care was provided exclusively by one’s family and community.

“When a person fell sick, the family took care of her. When a person grew old, the family supported her, and her children were her pension fund. When a person died, the family took care of the orphans.”

Yuval Noah Harrari

But those functions of family and local community have largely been taken over by government and business. Harari calls this “the most momentous social revolution that ever befell humankind: the collapse of the family and the local community and their replacement by the state and the market…

As best we can tell, from the earliest times, more than a million years ago, humans lived in small, intimate communities, most of whose members were kin. They glued together families and communities to create tribes, cities, kingdoms and empires, but families and communities remained the basic building blocks of all human societies.

The Industrial Revolution, on the other hand, managed within little more than two centuries to break these building blocks into atoms.”

Juergen Habermas

Jürgen Habermas during a discussion in the Munich School of Philosophy. Photo by Wolfram Huke

Jürgen Habermas, one of Europe’s most esteemed intellectual elders, describes how the modern “system” of government and business has pushed aside the ‘lifeworld’ of family, friends and community. The system’s professionals provide care because they are paid. The lifeworld’s family and friends look out for each other because they care.

In building a new reality, we propose to increase the influence of family, friends and community; not because it seems like a nice idea, but because the evidence indicates that things actually work better when you do.

Empowering Families With FGC

In 1998, I attended a professional event in England where I heard a grandmother describe how terrified she was that county social workers were going to place her grandchildren in foster care because her daughter, a single mother, was suffering severe depression.

The grandmother poignantly described her family’s feelings of helplessness and desperation in the face of the power of government, however well-intentioned, to sweep into their lives and take away the grandchildren that they loved so dearly.

However, the skies sudden brightened for the grandmother and her extended family, when the county social service agency offered them the opportunity to participate in a family group conference (FGC).

Instead of the “system” and its social workers making decisions about children without their family’s involvement, family members were invited to develop their own plan for the children. Grandparents, aunts and uncles rallied around the struggling mother.

In the FGC, they organized a structured schedule of visitation and family support at critical hours of the day that ensured the wellbeing of her children. The plan they developed was sufficiently rigorous to satisfy the concerns that had brought about the threatened intervention by government.

The FGC was first developed in New Zealand as a response to the Maori—that country’s native people—who were alarmed by the frequent removal of children from their homes in child abuse and juvenile delinquency cases.

Under an innovative 1989 law, before the courts can remove children from their homes, either for delinquency or child abuse, families must be given the opportunity to develop their own plan to keep their children at home. The law’s most radical provision requires the authorities who convene the meeting to leave the room and allow the family to meet in private; informally called “family alone time.”

The Little Book of Family Group Conferences

The net effect of this new law, according to former New Zealand Judge Fred McElrea, “was that many expensive institutions were able to be closed, and court sittings dealing with young people were greatly reduced.”

New Zealand has moved away from the idea that experts know best. Rather, it engages families, empowering them to guide outcomes. Nor has New Zealand allowed social workers to limit which child gets a conference, resulting in well over 100,000 conferences since the law went into effect.

McElrea points out that the outcome has been unquantified, but that it has realized “substantial savings—not only in dollar terms, but also in terms of the unintended damage that those institutions can cause.”

The New Zealand development of the family group conference has influenced practices throughout the world. In the United Kingdom, the majority of local jurisdictions employ FGCs at times, though—unlike New Zealand—only in a few locales are they mandated for all children taken into care.

Daybreak, the leading FGC provider for children in the U.K., was one of the earliest adopters of the approach, and also pioneered family group conferences for vulnerable adults who have disabilities or who have experienced elder abuse.

Daybreak Logo

As an independent agency organizing and coordinating the FGCs, Daybreak assists families in confronting the awesome power of the state, giving the lifeworld more influence in system decisions.

An African-American grandfather from Los Angeles explained that he didn’t like social workers, “because of my past experiences with the Department of Children and Family Services and the way that they operate. In our community they’re not very well-liked, you know, social workers and the whole bit.”

After experiencing an FGC, the grandfather asked, ‘Who died in the Department of Children and Family Services and let them do something so terrific?’

In the United States and Canada, FGC is usually called family group decision-making (FGDM).

The story of the African American grandfather is from Family Voices, an 18-minute video with families from Pennsylvania and California who participated in an FGDM meeting for themselves or a family member.

In my home state of Pennsylvania, nearly half of its 67 counties have actively implemented FGDMs, signaling “a significant shift in how families are engaged in decision-making to resolve concerns.”

A review of research by the American Humane Association reported that plans developed by FGDM in child protection “are more likely to keep children safe, result in more permanent placements, decrease the need for foster care, maintain family bonds and increase family well-being…for even the most challenging child welfare situations, including neglect, domestic violence, substance abuse and sexual and physical abuse” (Merkel-Holguin, 2005). 

Transforming Care: The New Welfare State

Rob van Pagée, founder of Eigen Kracht Centrale—an agency that has organized more than eleven thousand FGCs in the Netherlands—has criticized his own “system thinking” as a young professional social worker.

Eigen-Kracht Centrale Logo

In an article entitled Transforming Care: The New Welfare State he wrote:

“They were my families.

“They adapted to my way of working.

“They came to my office, at a time chosen by me.

“They learned my professional jargon.

“It was about my explanation of their problems.

“Our organization prescribed the solution.

“We generally used one, not particularly broad, range of solutions.

“I saw countless problems that were connected, such as poverty, poor housing, debt, medication use and unemployment, but I focused mainly on upbringing and development opportunities.

“I didn’t know the debt restructuring, housing association or job centre experts; these were in other offices.”

Rob van Pagee

As Van Pagée came to recognize the shortcomings of the system, he embraced the New Zealand FGC and brought it to the Netherlands and other countries in Europe. He further explained how FGC is changing the attitude of the system toward families.

“We recognized that those families described in my first job as ‘people with problems’ are also the experts regarding the history and development of their issues. Their own stories, told in their environment, which developed within their own network and with people who count for them, also provide the source for a solution.”

Because Eigen Kracht Centrale’s conferences are high quality, the research results are compelling. A world leader in conferencing, the Dutch non-profit organization has developed a reliable and cost-effective approach: using non-professionals trained as coordinators.

Hundreds of volunteer coordinators accommodate the wide diversity of foreign languages and cultures among immigrants in the Netherlands, something that government itself would struggle to afford.

“Research shows that Eigen Kracht conferences are effective, even in complex situations where youth care is involved, in cases of domestic violence, as well as where so-called multi-problem families are concerned…

“Most plans are executed, the problems are solved and escalation is prevented.”

Eigen Kracht conferences are also cost-effective. This is because families tend to use their own resources. Instead of requesting residential care, as professionals often do, the families arrange for help at home or for foster care instead of residential youth care. When there is not an FGC, typically those cases cost about twice as much as those for which there was an FGC (Eigen Kracht Centrale, 2004-2009, 2).

Still, social work professionals often resist the idea that families can make their own decisions, finding all kinds of reasons why a conference “wouldn’t work” and why professional decision-making would be better.

CSF Buxmont Programs

For example, at the Community Service Foundation (CSF), one of the two youth-serving organizations my wife and I founded in Pennsylvania, our staff proposed a family group decision making meeting for a teenage girl who was approaching her 18th birthday.

At that time, she would leave our residential program and alternative school and no longer be supervised by the county’s children and youth agency. She had been under the supervision of the county for more than a decade, after one of her parents went to prison and the other died. We wanted to reconnect her with family members so she would have a natural support network.

The county social worker questioned the merits of the conference, because she was of the opinion that there were no interested family members in the region.

After developing a written family tree with the girl, CSF staff helped her reach out to relatives who lived locally and beyond, inviting them to reconnect with her at a special meeting. The social worker was pleasantly surprised when a dozen family members turned up at the FGDM to support their long-lost cousin or niece, whom they last saw as a small child.

The teenager found herself surrounded by love, with a renewed family network and a written plan defining—in specific terms—how her relatives would support her to became an independent young adult.

This story demonstrates the rich possibilities when the system engages the lifeworld in decision-making.

Notably, the “doing things with people” spirit at CSF and Buxmont is woven in to the fabric of organizational life. When beginning a CSF Buxmont program, young people and their families are asked to set the primary goals for the young person’s treatment plan. They are given user-friendly written materials designed to make it easy to review the possibilities, discuss them and choose priorities.

In the past, staff members would write the treatment plans and ask parents to sign the document in agreement. Instead, now families provide meaningful input. Parents often comment that no one has ever before asked their opinion about their child and what would be best. Decisions were usually dictated by the system’s professionals.

CSF’s and Buxmont’s treatment planning mirrors the values of the New Zealand FGC, giving families more voice and choice, if they take responsibility for reviewing the possibilities and making thoughtful choices.

Family groups are remarkably conscientious when they trust that their opinions matter and that they can play a meaningful role in deciding on care for their loved ones. As for the CSF Buxmont programs themselves, they are designed to encourage young people to support each other in resolving their own problems.

CSF Buxmont

To understand how challenging young people are successfully engaged, the following two online articles may be helpful. Two Pennsylvania journalists reported on their separate visitations, one at a CSF Buxmont school day program, and the other at a CSF foster group home.

“The Worst School I Ever Went To,” the second chapter in my Dreaming of a New Reality book, tells the story of Tim Cassidy’s year at the so-called “worst school,” and how it transformed his life for the better.

The chapter describes the CSF Buxmont school program and reports on its dramatic research outcomes, including more than fifty percent reductions in criminal offending among the nearly 4,000 young people who participated in CSF Buxmont programs from 1999-2006.

Years later, Tim Cassidy and others recorded video testimonials about how CSF Buxmont helped them turn their lives from a negative path.

Stockholm City Mission

Stockholm City Mission, a 150-year-old Swedish private institution, uses restorative practices in its homeless shelters to engage clients in addressing their own behavior problems, instead of staff-imposed punishments.

“We have a big empathy issue in Sweden,” says Mija Bergman, manager of Bostallet (the Homestead), a halfway house for homeless men and women.

Bostallet

“We are so understanding. It’s in our self-image and our culture, and in our history as a social welfare state. The problem is that we feel so sorry for these poor homeless people, so we figure out very good plans of how they should deal with their problems, and then we inform them, ‘you should do this and you should do that,’ and they get furious!”

The appeal of restorative practices for Stockholm City Mission was that it encouraged staff to do things “with” clients, rather than “to” or “for” them. In doing so, it reduced the burnout for staff members who no longer tried to solve everything for their clients.

In 2000, Klaragården, the Mission’s day center for homeless women, began using restorative practices. With the new approach, Bergman explains: “As soon as you do something that violates the cardinal rules—if you are threatening, use violence, if you’ve taken any drugs—you have to leave. But you can book an appointment to come back.” The process is about reintegrating people into a community, instead of excluding them. “No matter how mentally ill they are, we always hold clients accountable for their behavior and their actions,” says Bergman.

Stockholm City MIssion logo

Two women stole some cash from the Mission to buy drugs, and rather than being banned from the shelter, they were asked to participate in a process to decide what would be done. They were shocked when they were asked how they were going to repair the harm they had caused.

As an act of contrition, the women offered to clean Klaragården’s heating system radiators, which proved to be a formidable task. It took them the whole summer to complete. Interestingly, the two women were extremely proud of their work. Despite their mental illness, they have been able to stay at the shelter and for years afterward, boasted of their “very good reparative work.”

Bergman commented, “I think it was the first time that they had actually been able to repair something, and it made them feel good. It’s about pride, I think. They restored my faith in them and my trust in them. But they also restored their own pride, in taking responsibility for what they had done.”

Oranjehuis

Oranjehuis (“Orange House,” in English) is a Belgian agency that uses restorative practices, from its residential drug and alcohol treatment program to its organic farm project and other day programs for young people and their families.

Founded in 1974, Oranjehuis independently developed counseling strategies similar to Community Service Foundation and Buxmont Academy. But after its senior leadership visited CSF Buxmont in 2004, it began using the term “restorative practices” to describe its underlying approach.

Oranjehuis

The agency established an organization, Ligand, to train its own staff in restorative practices, as well as schools and other youth-serving agencies across Flanders, the Dutch-speaking part of Belgium.

Most recently Oranjehuis developed a project called the “Columbus Program,” to reduce waiting lists for youth and family counseling services in cities across Flanders. While waiting for assistance, families often saw their problems get worse. A more timely intervention would likely have prevented escalation.

Beginning with a pilot region in 2010, Columbus has now been implemented in communities across Flanders.

Columbus Program logo

Quoting from the website:

“Columbus focuses on communication and connection. Everyone’s story and perception of the situation is listened to and exchanged with each other to work together to find solutions. We are confident that each family can make a contribution in this quest.

“Columbus supports the entire process and its follow-up. As a family finds the strength to address obstacles and difficulties inherent to tackling life itself, we adjust our intervention.”

Each solution consists of:

  • Speaking, really listening, and deciding together
  • Taking responsibility (everyone has a stake in the development and addressing a problem)
  • Making (common) positive movement
  • Existential answers to existential questions

Rather than relying on the perceptions of a therapist or expert, the Columbus program engages families in finding their own solutions. Columbus is involved for a maximum period of 4 months. Some families may need other services, but the timely intervention by Columbus helps them cope until those services become available. Most do not need more services and many families do not even need to be involved for the full four months.

The Sanctuary® Model

Dr. Sandra Bloom has developed a blueprint for building a participatory community; not just among those in treatment, but among those people and systems who provide that treatment.

Dr. Sandra Bloom

Dr. Sandra Bloom, photo by Chenoweth

Although Bloom and her associates do not formally use the term “restorative practices” to describe their work, it matches that modality perfectly, including the extensive use of circles, in which each person speaks in turn without interruption, and the opportunity for everyone to be heard.

“Creating Sanctuary” is an organic process that happens over the course of time to move an organization from a top-down hierarchal structure toward a participatory, trauma-informed culture “that recognizes the inherent vulnerability of all human beings to the effects of trauma.”

Creating Sanctuary book

The Sanctuary Model engages clients and staff in a way that demonstrates the new reality of doing things “with” people, rather than “to” or “for.” The Sanctuary Model originated in the Philadelphia area in the early 1980s, created by a team of clinicians working in a small inpatient adult hospital unit.

The model has since been implemented in more than 275 organizations worldwide, advancing the development of a new reality in a variety of human service settings.

A Restorative Nursing Home

In an IIRP eForum news article, Joshua Wachtel writes:

“Nursing homes, even very nice ones, tend to regiment life for their residents, based on the rhythms established by the institution. But at Maranatha House Aged Care Facility, staff have taken a different approach to help residents ‘live life my way, made easy,’ to paraphrase the organization’s motto. Restorative practices is helping Maranatha fulfill that mission.

Debra Wells

General Manager Debra Wells says the idea is to ‘deinstitutionalize’ the system and ‘put residents in charge.’ Rather than having to live each day by staff routines, residents at Maranatha, in Wellington, New South Wales, a town and rural region of about 10,000 people located 225 miles from Sydney, Australia, are greeted with choices and conversations that allow them to express their needs.

Wells criticizes the institutional approach: ‘It makes aging a medical illness instead of a process that happens to all of us. At Maranatha, we’re having the right conversations with residents and their families instead of hiding behind red tape and bureaucracy.’ ”

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