by John Burton
Date Posted: Sunday, 14 December 2008
John Burton has over forty years’ of experience of working in and managing in a wide range of social care settings. He has been an inspector and teacher, an advocate for residents and relatives, and a campaigner for improving social care standards. He is the author of two books, including ‘The Handbook of Residential Care’, many contributing chapters and countless articles relating to care as a vocation and a profession. In his current role as an consultant and external supervisor John helps caring organisations to evaluate their services and improve them. John is also a committed cyclist. You can find out more about John’s work at www.standardsforpractice.co.uk This article first appeared in Caring Times in April 2007.
Care is Therapy
It’s time to recognise and be proud of what we do
In common with several colleagues of “a certain age” (my fellow Caring Times columnist, Martin Wigg, for example), most of my early years in social care were spent working with children and young people. My qualifying training is “the certificate in the residential care of children and young people” (CRCCYP). In the 1960s and 70s, those of us who took this profession seriously aspired to do “therapeutic work”. Our models were places such as The Mulberry Bush and later The Cotswold Community and Peper Harrow. Amongst our “gurus” were Barbara Dockar-Drysdale, Richard Balbernie and Melvyn Rose.
The care home as a therapeutic environment
I was fortunate to have had further training from people such as Chris Beedell and Roger Clough at Bristol University, at the Tavistock Clinic, and later training as a counsellor, groupworker and organisational consultant. With this background, working in and with care homes for all ages, disabilities and conditions, I have never had the slightest doubt that our work is “therapeutic” at its core. When I was an inspector I saw much more than physical standards and paperwork; I looked for therapeutic relationships, and social and emotional wellbeing; I looked at the “whole” home. Long ago we used to use the phrase “therapeutic milieu”, meaning that the whole home (staff, building, food, the day-to-day life of the home . . . everything about the place) was therapeutic. Yet “therapy” – in this sense – is not now much used as a concept in relation to care homes.
The contribution of residential child care
Residential child care is probably the most recognisably “therapeutic” of all care provision. Good care for children and young people in children’s homes has to be based on therapeutic relationships. Children living in a home need to be able to form relationships with reliable and committed adults who understand the child’s emotional and psychological background and needs. Therefore the home must be set up in a way that can provide real relationships, comfort, security and control.
But the therapeutic care provided in good children’s homes is not essentially any different from the care provided in good homes for adults (of all ages). All care comes through person-to-person relationships whether it’s for a child, a teenager, an adult with learning disabilities, or an eighty-five-year-old with dementia.
Child care social work has contributed much to the practice of care homes for adults. The Social Care Association (SCA), originally the Residential Child Care Association (RCCA), has for many years brought together a cross-section of social care professionals and organisations, and has maintained an emphasis on therapeutic work in all settings. And recently more child care organisations have joined the National Care Association (NCA) opening up a great potential for promoting the concept of therapeutic care throughout the diverse care home sector.
Training for therapeutic work
For too long the emphasis in training care workers has been on the “actions of care” rather than the relationships, emotions and psychology of care. All good care workers work through relationships. If you think about bathing a resident for example – or, better, helping a resident have a bath – while it is of course important to know how to “do” it (the physical side), the relationship work (the therapeutic work) involved is the overriding issue. Experienced care workers know that this is one of those times when some residents talk about themselves in a much more intimate and emotional way. The real training for doing this work is principally through “action learning” – learning from doing it, from the residents and from experienced colleagues, and from discussing it afterwards with your supervisor and possibly in handovers and team meetings. There are thousands of care workers out there, working at a deep and complex level, yet receiving neither the recognition nor training they deserve.
The small care home
And for generations the traditional NCA membership – of which the backbone must still be the owner-managed small care home – has been practising therapeutic care. Take for example the fifteen- or twenty-place home, well established in its locality, where many of the residents have known the home, the other residents and the staff long before they come into it, where the home is a truly valued part of the local community, where staff relate to the residents in a very personal and direct way, where there’s a true feeling of “big family” or “small community” – this is a therapeutic care home.
Of course behind the scenes there are structures, procedures and a good deal of management and administrative expertise to make this happen. But we have tended to disconnect this sort of management from its purpose – from the “primary task” of the home. The management of a home is only as good as the care given. The manager of a care home is the manager of the whole therapeutic task, and must measure every action by its therapeutic effect.
In recent years all care services have been struggling to keep up with and comply with centrally imposed requirements, guidance and regulations. For many homes it has felt as if it was getting increasingly difficult to provide care in the way that they had always wanted – through reliable, therapeutic relationships – because they were always trying to catch up with what outsiders required of them rather than what their residents really needed.
But some homes have managed to get ahead of the game and have continued to provide and develop therapeutic care. Such care is always innovative because each resident is different and needs a very personal and individual response.
All homes which care for people with dementia (and this is virtually all care homes for older people) will invent a particular way of working for each set of individual needs, just as all children’s homes have to provide special relationships and exactly designed responses to each child’s needs. But we do not work only with individuals; we work with groups and with a community, so we need to create an environment and a way of life in the home that are in themselves therapeutic.
Homeliness is therapeutic
As a social care consultant, I am frequently contacted by managers and proprietors who feel that their home and the care they provide has been undervalued and misunderstood – often by inspectors. Although I don’t see all these homes, I guess that a good proportion of them are providing excellent therapeutic care. For example, homes where the care plans are brief and perhaps a bit untidy, and the statement of purpose is not phrased in the approved fashion, may nevertheless have superb staff/resident relationships and residents feel genuinely “at home”. In such homes, domestic workers may be doubling up as care workers and although the care appears to be informal and unplanned on the surface, residents are getting loving, reliable and very individualised attention.
Of course there are dangers in assuming that all is well simply because the residents appear to be happy, fulfilled, and involved, and the staff are so committed to their work that they willingly respond as friends to residents’ needs. I am not saying that good record keeping and clear roles and relationships aren’t needed. But you can have both, and if on occasions you have to prioritise, the value of a truly caring relationship and truly therapeutic care far outweighs the value of the paperwork and approved procedures.
In a care home, it is what goes on between people (relationships) that counts. In an excellent care home these relationships are examined and open to scrutiny; staff learn that care is therapy, and therapy requires planning, evaluation and support for the staff who practise it. But therapy is best achieved in a home that really feels like home.