Paper
Contextual practice in residential care: the Cano projects
- issue: Issue 2 / 2008
- authors: Hans Grietens
- keywords: Belgium, outcome, residential care
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abstract
Background. CANO is an acronym for Centrum voor Actieve Netwerking- en Omgevingsondersteuning . It is an initiative taken in 2002 by staff members from eight residential care services to install empowering contextual practice for very troubled and troubling youth. The principles underlying CANO practice are agreed upon in a charter which has been implemented in each service according to its specific situation and conditions. The services do not get extra money for participating in CANO, but all services have at least one project funded by the government which gives them some extra (e.g., an extra staff member).
In this paper, we first give an outline of the CANO projects by describing the target group, the areas of intervention, the concrete practices and the conditions that need to be fulfilled. Next, we present a summary of results on the outcomes of CANO.
Target group. The target groups of the CANO projects are troubled and troubling young people and their environment. Both are in need of support because the interactions between them are severely disturbed. Both the young people and their environment suffer for a long time under these disturbances and do not have sufficient power to regain control over their lives and repair the bonds that have been ruptured. Further, many young people have a background of discontinuity, instability in the family life and severe trauma caused by physical or sexual abuse and neglect. Their families of origin are highly vulnerable, socially isolated and focussed on 'surviving'. The survival strategies they have developed often are characterised by negativism and a lack of adequate care. Their problems and the vicious cycle they live in are often repeated across generations.
The young people referred to the CANO projects show a lot of severe emotional and behavioural problems. Many symptoms can be considered as distorted ways to communicate internal distress, anger, frustration and anxiety. Boys use to communicate by externalising problems, for instance physical violence, delinquency, aggression, and so forth, while girls tend to communicate by internalising problems, for instance auto-mutilation, suicidal ideation, depressive behaviour, and so forth.
The majority of the young people have already a long 'career' in the care system before entering the CANO project, with several breakdowns of placements in foster or residential care. It seems that there are no services available to help them and the accumulation of breakdowns and negative experiences in care give them the feeling of being ignored and socially excluded. Often, they have lost their belief in the care system and are no longer motivated to be helped.
Areas of intervention. CANO intends to be an integrative care model which tries to break the chain of social exclusion and negative care experiences of young people and their environments. This is illustrated by the areas of intervention which are multi-fold and interconnected, so that flexible transition from one area to another is possible without creating discontinuity or ruptures. There are four areas of intervention: 1) contextual treatment, 2) individual treatment, 3) residential treatment and 4) the day programme.
Concrete practices. The CANO projects are not based on a fixed programme. This makes that there is no such a thing as 'the CANO method' or 'the CANO intervention'. Every service involved in CANO has implemented and concretised the project according to its specific situation and culture of care. Services now are trying to write a formal protocol to make explicit the working principles of CANO. The common practices can be grouped into three themes, according to the underlying objectives: connecting (e.g., by family group conferencing, round table consultations), creating a reflective base in the minor (e.g., by time-out projects) and restoring (e.g., by planning a restorative circle following an aggressive or delinquent act).
Conditions. In every CANO project certain conditions need to be met in order to set up interventions reflecting the underlying principles to the benefit of the young people and their families. The CANO workers have specified following conditions: 1) Flexibility: CANO needs flexible transitions between young people's contexts and the residential unit, 2) CANO projects have to be accessible 24 hours a day for young people, their parents or other people involved, 3) Commitment: CANO workers should know they have to provide help in difficult and complex situations and 4) Organisation: CANO projects need to be embedded in flexible and interdisciplinary services consisting of enthusiastic, proactive and open teams, dialoguing permanently with all partners involved in the child and family welfare system.
Outcomes of CANO. In 2006-2007 we conducted a study on the outcomes of the CANO projects, ordered and financed by the Flemish Ministry of Welfare, Health and Family (Grietens, Mercken, Vanderfaeillie, & Loots, 2007). We briefly summarise the research questions, methodology, main findings and conclusions. More information on this study can be found in Grietens (2007).
Research questions. Questions were addressed with regard to the target group, the interventions and the outcomes.
- Questions regarding target group: which are the target groups of the Cano projects and do the projects reach the target groups they intended to reach?
- Questions with regard to the interventions: which interventions take place in the CANO projects? For which goals? Which models or programmes are the interventions based upon?
- Questions with regard to outcomes: what is the dropout in the CANO projects? Do CANO trajectories reach their goals? Is there a significant reduction of child problems and problems within the parent-child relationship?
Methodology. Different methods of data collection and analysis were combined in order to answer the afore-mentioned research questions. Reports and documents about the CANO projects were analysed to find out how target groups were identified. This information was cross-checked during semi-structured interviews with a staff member. To study the profile of the minors and their families entering and leaving CANO projects case files were studied. A random sample of 100 cases (10 within each project) was drawn by asking each CANO project team to complete a semi-structured questionnaire about the last ten cases ended before May 2006. The questionnaire contained items about the child's psychosocial problems and problems within the parent-child relationship at the beginning and the end of the trajectory, as well as items on treatment goals and interventions used in the projects. The latter information again was cross-checked by means of a semi-structured interview with the staff member. During the interview which lasted between one and two hours, the staff members were asked to describe the outcomes of CANO as well as pitfalls and current problems. All teams agreed to participate at the study. The questionnaires were analysed using statistical techniques (mainly descriptive statistics were computed), the interviews were tape recorded, transcribed and analysed using qualitative data analysis techniques.
Main findings. The majority of young people in CANO showed severe psychosocial problems (externalizing as well internalizing problems), with most of the young people having a long and discontinuous care history and a great number of placement breakdowns. One out of three young people showed psychiatric symptoms and a similar number had been the victim of some form of child maltreatment. Practitioners strongly agreed upon the inclusion criteria for CANO: there were nearly no reasons to refuse a minor in the project, except in case of severe mental retardation. The length of stay in CANO varied from six months to three years. Due to the complexity of their problems the majority of the trajectories were planned for a long-term. Staff members agreed that it is difficult at entry to estimate how long a trajectory would take.
Dropout, goal attainment and problem reduction were taken as outcome measures. Dropout rate was 29%. Dropout was due to lack of motivation, severe drug abuse, fugues or severe aggression. Young people leaving the programme showed significantly less problems (e.g., externalizing problems, psychiatric problems, acting out, drug abuse) as compared to entrance. Similarly, problems in the family and the parent-child interactions decreased significantly. Nevertheless, the level of problem behavior remained high and practitioners admitted that although some treatment goals were reached (in particular, goals related to the school and to psychiatric compaints), the majority was not or only partially.
Conclusions. CANO is a promising good practice for severely troubled and troubling youth in residential care. In Flanders, it is gradually getting the status of a 'practice-based evidence'. It will be implemented on a larger and a more formal scale. One of the main strengths of this project is that it is based upon an explicit theory of change. Further reflection learns that following elements may also contribute to the success of CANO:
- creating 'synergy' between young people, families, networks and professionals by sustaining a collaborative and continuous dialogue;
- 'going one step further' in developing and maintaining a professional relationship with the clients and this by using power in the relationship in a mindful and judicious way and by expressing a humane attitude and style which goes beyond the 'traditional' professional relationship (de Boer and Coady, 2007), a characteristic of helpful professional relationships;
- commitment and belief in social networks as powerful agents of change;
- a view on residential care as part of an integrative care system.
However, the dropout rate and the interviews we conducted with practitioners showed that CANO has limits as well. Some necessary conditions (e.g., flexibility, professiona¬lisation) need to be fulfilled and in the near future exclusion criteria should be formula¬ted.
Key references
de Boer, C., & Coady, N. (2007). Good helping relationships in child welfare: Learning from stories of success. Child & Family Social Work, 12, 32-42.
Grietens, H. (2007). Contextual practice in residential care services in Flanders: The CANO projects. In H. Grietens, E. Knorth, P. Durning & J. Dumas (Eds.), Promoting competence in children and families. Scientific perspectives on resilience and vulnerability (pp. 223-246). Leuven: EUSARF and Leuven University Press.
Grietens, H., Mercken, I., Vanderfaeillie, J., & Loots, G. (2007). Initiatie van effect- en effectiviteitsmeting van het private hulpaanbod binnen de bijzondere jeugdzorg. (Report for the Flemish Ministery of Welfare, Health and Family). Leuven: Katholieke Universiteit Leuven.
Contacts: Hans Grietens, Centre for Parenting, Child Welfare & Disabilities, Katholieke Universiteit Leuven, Vesaliusstraat 2, 3000 Leuven (Belgium), E-mail: Hans.Grietens@ ped.kuleuven.be