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2. VOICE

Introduction

The importance of young people having a voice in the decisions and experiences that impact them and in their everyday life has long been recognized both in scholarly literature and in the work of service providers across child and youth serving sectors. The concept of ‘doing with’ rather than ‘doing to’ or ‘doing for’ young people is often cited as a way of distinguishing the construction of young people as subjects versus objects. Inherently, to the extent that treatment approaches are based in medical models of service provision, the risk of continuing the construction of young people as objects exists (AACRC, 2014; Allan et al., 2011; Brendtro & Larson, 2004; Child Fund Australia, 2012).

Government strategic directions, service plans developed by child and youth serving agencies, and previous Panels and consultations have cited the need for a coherent and meaningful strategy to ensure that young people are active participants in their experience in out-of-home care. The Blueprint for Fundamental Change to Ontario’s Child Welfare System (2013), identifies as essential and urgent that the group care system is evaluated to make sure that it focuses on the best outcomes for youth, starting with a process that listens to the voices of youth in and from care. In addition, a recent report from Kinark Child and Family Services (2015) states that empowering youth to be equal decision-makers in their own treatment is particularly important in health-related fields, including residential treatment programs, where traditional structures have created inherent power differentials between youth and caregiving adults. Young people themselves have consistently stated that the opportunity to have a direct involvement and a meaningful role in the decisions that affect them is of critical importance.

The recognition that young people’s voices are important stands in contrast with the expert-driven nature of much of the residential services system. We heard from young people that major decisions that have a direct and often life altering impact on young people continue to be made without their direct involvement, or without a significant weighing of the perspectives presented by young people. A recent draft report from Children and youth mental health Ontario (CMHO, 2015), for example, proposes a significant restructuring of the children and youth mental health system, including residential treatment services, without reference to young people’s voices at all. This in spite of the report acknowledging the critical importance and extensive evidence related to the benefits of youth participation and engagement in their involvement with services (p.9). Young people and CAS-based Children’s Services Workers indicated to the Panel that this often includes placement decisions, where young people often have no role in determining either the type of placement or the specific service provider they may prefer.

Notable contexts in which the voices of young people are key include the development of programs and services for young people in out-of-home care, the governance and accountability frameworks for such services, the design - including the rules, procedures and physical design of programs and services - as well as the treatment, relationships and caring that unfolds in programs and services. Of great importance is the active involvement and joint decision-making between young people, families and professionals in the context of major transitions, such as the transition into out-of-home care, the transition between placements, and the transition out of out-of-home care, including into emerging adulthood.

The Panel was told that the issue of voice extends beyond the participation of young people in their own lives; within the residential service sector, the voices of direct care providers (residential front line staff, foster parents, youth services officers) also have often not found opportunities to be heard and to have their perspectives fully integrated into decision-making. Similarly, the voices of families, including parents, siblings, grandparents and extended family or kin are often very peripheral to the expert-driven approaches in service design and governance.

In spite of shortcomings, the Panel is impressed with several initiatives aiming to ensure the inclusion of young people in the design of residential services and feedback about young people’s everyday experience. A longstanding example of this is the Youth Amplifiers who work with the Office of the Provincial Advocate for Children and Youth to consult with young people in care to ensure that their experiences in care are known by others. Other examples include New Mentality, a youth group and program in the children and youth mental health sector, and YouthCan, a youth group in the child welfare sector that works to represent the voices and experiences of young people in care. The Panel supports these aforementioned initiatives, and moving forward feels that it is important for young people who are not likely to join such groups to be given alternative opportunities to have their voices heard.

Issues

Across Ontario’s residential services system, there is a general appreciation that the voices of young people living in residential services are important. During its consultation sessions, the Panel encountered a wide range of approaches that aim to provide opportunities for young people to express their unique needs. However, except for the aforementioned youth groups facilitated and supported by major organizations such as PACY, CMHO and OACAS, these approaches are inadequate at the agency and system levels when aiming to provide youth with meaningful ways to actively participate in their service experience at all levels of that experience. For example, holding regular focus groups in order to elicit youth perspectives or ensuring that young people are involved in their Plans of Care are not in and of themselves sufficient mechanisms of engagement. The Panel heard repeatedly in its consultations with young people and also with child protection staff, foster parents and residential staff that plans of care processes vary significantly from program to program and even from worker to worker. These processes are often not seen as providing young people with meaningful opportunities to be partners in their own care.

Many young people report a high level of disengagement and disempowerment within their everyday experience of care as well as their trajectories through care. They elaborate that they feel that their inspiration for their life and future and their unique sense of self is continuously challenged by professionals and a system that they believe should embrace them. Young people cited examples such as being streamed into vocational education against their wishes, being discouraged from pursuing their professional aspirations if these appear as incongruent with their educational achievement, and in some cases being discouraged from exploring their cultural, sexual and lifestyle identities.

The voices of young people in the system of residential services are frequently minimally represented in decision-making at the individual case, program and system levels. While there is often an emphasis on individualized treatment plans and plans of care, the mechanism of individualization also serves to fragment and minimize the collective voices of young people impacted directly by these services when these processes are implemented in a mutually exclusive manner. While it is in fact important to maintain Plans of Care and related interventions as highly customized and personalized in order to engage the unique context of young people, the voices of young people, like the voices of the professionals who work with them, need to be heard as a collective and encompass all levels of service provision, including governance, accountability, system design and specific program contexts.

The Panel is concerned that we did not hear of any mechanisms, or even initiatives, to ensure that young people with complex needs, including non-verbal young people and young people with developmental challenges, also have a voice in what happens to them within the residential service system. Furthermore, the Panel notes that the most common mechanism to listen to young people involves group formats, which excludes many young people uncomfortable in such formats. It is worrisome that residential services across sectors have not developed a menu of opportunities to provide feedback and contribute to service design involving contexts suitable for the rich diversity of young people in out-of-home care. Constant efforts are required to include the voices of the full diversity of young people.

Residential services across sectors are characterized by a high commitment to professional expertise, often at the exclusion of the expertise embedded in the lived experiences of young people and their families. Historically, residential care was firmly based on a medical model of practice, with a deficit-based approach in which professional experts operated under the assumption that they would be able to “fix” the young people who received care in this system. As a result, young people living in residential services often had no agency and voice. Although today there is much rhetoric and also increasingly authentic attempts to recognize young people’s agency, voice and valuable expertise based on their lived experience, many major decisions in a young person’s life, including issues related to the use of psychotropic medication, the types of treatment they receive, and the location and types of placements they are offered, are made by professional experts without youth participation. The Panel heard from clinical staff and social workers in several consultations that decision-making about young people particularly in the context of placement decisions can involve additional pressures related to cost containment.

The voices of families of young people involved in the system of residential services, including in children and youth mental health residential treatment services, often appear to be peripheral, especially in the context of major decisions impacting the life of a young person. Although the Panel heard many instances where young people reconnected with their biological families including their siblings following their discharge from the system, these families were not effectively included in residential services while that young person was receiving programs and services. In the Panel’s consultations, a young person’s family was either rarely referred to or referred to in negative ways by residential front line staff and foster caregivers. In the Panel’s research beyond the consultations, very few examples of services and programs were found designed specifically to include and effectively engage families. In the context of residential treatment, family work is often cited as the key ingredient of the treatment, yet the Panel heard repeatedly that families who are not immediately responsive to the attempts to engage them in the treatment process by the service provider are viewed as ‘difficult’ and often seen as the cause for treatment breakdown. The Panel is concerned that a family’s social location, which includes their socioeconomic status, education and race, can have an impact on access to resources resulting from varying capacities for self-advocacy.

The Panel was surprised to learn that immediate caregivers, including front line residential staff in group care and foster parents, see themselves as peripheral in the decision-making processes about the children and youth they care for, and also in the design of the programs and services they are tasked to deliver. Their voices, based on significant accumulated experience of being with young people where they live, and of providing for the needs of young people for ‘the other 23 hours’, appear to not be fully integrated into what are often described as multi- or interdisciplinary teams. In some instances, the Panel heard about evidence-based practices in some residential treatment programs that staff we spoke to in that program were unable to confirm or even identify. When management teams and front line care givers operate in silos, it represents a lost opportunity to meet the needs and hopes of young people.

Implications for Recommendations

The overall context of the Panel’s recommendations with respect to Voice is a mitigation of the top-down, expert-driven model of service provision in which the lived experience of young people and their families are marginalized. Given strong support amongst service providers for the importance of youth voice, engagement and participation in all aspects of service provision, there is an opportunity for MCYS to provide leadership in ensuring that this broad endorsement is put into practice in real and tangible ways. This recommendation aligns with a previous recommendation and theme from, My REAL Life Book – Report from Youth Leaving Care Hearings (2012), which notes that the province of Ontario should recognize the current system needs to fundamentally change by valuing and implementing the incorporation of young people in and from care in the governance and system design of the services and programs that are being offered throughout the residential system. To this end, many recommendations in other areas of this report will incorporate elements of Voice; however, some specific implications for recommendations follow from the above: