Discourses in Residential Child Care and Possibilities for Evidence-Based Practice

Talking about knowledge and methods

The interviews showed variances between informants who preferred to talk about treatment programs and manuals and those who preferred to talk about personal experiences, personalities, and different method combinations. Knut, one of the informants, described, in a detailed and engaged manner, the manual-based method with which he was familiar. Knut’s description of the methodological framework was peppered with technical terms, such as “multisystem,” “multiple teams,” and “institutionalized.” When talking about the method, Knut referred to “theories that display which methods are useful and which methods are not.” The comparison he made between “useful” and “not useful” indicates that Knut was convinced of this method’s effectiveness. Knut offered the following explanation of the advantages of the new approach:

In his explanation, Knut used both the methodological framework and references to research when comparing a standardized approach with other types of practices. He described the care unit as a place for treatment, not for living. By making this distinction between treatment and living, he opposed an approach to residential child care in Norway that involves long-term treatment and the establishment of intimate relationships (Hassel Kristoffersen et al., 2011, pp. 36–38). In the interview, Knut pointed to scientific knowledge as a better approach to professional decisions than interventions based on subjective emotional responses, as seen in families. Furthermore, he highlighted the importance of learning about the knowledge base and gaining confidence in how to practice the methods.

Sigrid was another informant who emphasized the usefulness of a specific manual-based treatment method. This emphasis is evident in the following interview excerpt:

Sigrid seemed to value having a tool that is directed toward specific behavioral problems. However, unlike Knut, Sigrid did not use technical jargon when she talked about the method. She instead related her understanding of practice to her own personal thoughts and to her understanding of the juveniles’ thoughts. Sigrid described ART as being a good technique for aggression management, but she was aware that the juveniles did not find the method to be useful. This combination of enthusiasm and ambivalence was notable in the interview with Sigrid, particularly when Sigrid made the following statement: “Sometimes I think that there is a fine balance between reinforcement and bribery.… It is kind of borderline.… But at the same time, the fact is that it does have an effect—that it works.” Sigrid talked about a detailed system of reinforcement that is an integrated part of one of the methods and compared the system of rewards with bribery. At the same time, she justified using the method by noting that it has “an effect.”

Jon, another informant, highlighted the importance of having the appropriate personal qualifications and knowledge of human interaction for professional practice. When talking about professional practice, Jon refrained from referring to theories or methods. He instead offered the following explanation as to why not everyone can learn to work in residential child care:

According to Jon, personality and involvement are important when working with people. He then contrasted personality and involvement with “what you have learned,” which can be interpreted as formal knowledge. Anita, another informant, highlighted how possessing knowledge of different methods is an advantage. When a variety of options are presented, the juveniles themselves can experiment to see which method works best. “One method will probably not fit all,” she said. Her comment does not lend support to the standardization of practice.

According to Anita and Jon, knowledge cannot be derived from theories and methods and applied to individual juveniles without being altered so as to fulfill individual needs and preferences. The professionals positioned themselves as important translators in this process, and the way they talked about the combination of education, personal life experiences, and personal qualifications pointed to discretion as an important component of professional practice. Discretion was not explicitly discussed by the informants but rather was implicitly comprehended as an aspect of practice in their understandings. Discretion is generally understood as the aspect of professional work that allows professionals to use their own judgment in applying general knowledge to particular cases. Hence, professional autonomy is required (Freidson, 2001; Lipsky, 1980; Schön, 1983).

Some of the informants emphasized the importance of exercising professional autonomy in decisions about applying knowledge and methods. Taking a different stance, Olav, the manager of one of the units, stated the following:

Olav talked about one of the (evidence-based) methods referred to in the introductory section of this article. When Olav exclaimed, “Now we have a tool!” he indicated that, unlike the current situation, tools were not available in the past. Like Sigrid, Olav used the word “tool,” which can be interpreted as representing an understanding of professional practice that is in need of technical means. In addition, Olav stated that “we have to have something specific.” He used the word “specific” when speaking about the new method. He also related the new method to standardization and employee loyalty when he commented that “it is as if everyone has to think the same way.” Olav’s satisfaction with a unitary approach can be related to his position as a manager (he was the only manager in the study). However, it is interesting that he also described all his employees as being enthusiastic about using this approach.

Therese, another informant, advocated taking a much different approach than the one emphasized by Olav. She perceived not being overly focused on using one particular method as a strength in treatment. In the focus group discussion, she talked about the methods’ relative impact on treatment compared with other aspects of treatment:

According to Therese, both the juveniles’ own resources and the establishment of good relationships are more important than the application of specific treatment methods in professional practice. By stating that “we are not overly focused on one method,” Therese also shows that she is aware of policy initiatives directed toward (methodological) standardization but that she does not believe it to be consistent with her understanding of practice. She refers to research results (“what actually works”) to legitimize a counterapproach.

As revealed in the interview excerpts, the informants sometimes expressed opposing views with regard to several aspects of knowledge and methods in professional practice. Tensions were identified between old versus new practices, what is useful versus what is not useful in treatment, scientific knowledge versus discretion, professional autonomy versus conformity, and methodological standardization versus methodological pluralism.

Talking about work objectives and outcomes

When the informants talked about work objectives and outcomes, tensions developed along the same dimensions. Olav was one of the informants who emphasized the importance of having clear objectives. He was happy to have finally gained a specific work objective: “The goal is, of course, abstinence. This is obvious and clear here. It is very good that we have gained such a clear goal.” In stating that “we have gained such a clear goal,” Olav appeared to favor the new practice over the old and to suggest that goals had been vague before the introduction of the new method. In the interview, Olav did not explain why he found establishing clear objectives to be important for practice. However, clear objectives can be interpreted as leading to both a reduction in uncertainty in professional decisions and an increase in the possibility of measuring treatment outcome.

In the following interview excerpt, Knut describes one of the standardized methods, highlighting the statistical outcomes:

Knut’s use of the term “success rate” can be related to an understanding of professional practice in which treatment outcomes can be measured in quantifiable terms based on the achievement of specific objectives. In the interview, Knut referred to both statistics and his own experiences when speaking about treatment outcomes. He spoke about being skeptical of the method in the beginning and then becoming more convinced of the method’s potential after personally experiencing changes in the juveniles’ behaviors. Neither Knut nor Olav related their understandings of outcomes to evaluations or feedback from the juveniles. Instead, they discussed outcomes as things that can be deduced from quantitative indicators of treatment progress combined with personal experiences.

Understandings of practice that differed from the emphasis on objectivity and measurable outcomes were also identified. An informant named Alf described the objective of residential child care is to provide juveniles with a general training for life. “This is training for how people treat each other in daily life within society’s laws and rules and how we achieve what we understand as a good life,” he said. Alf’s use of the expression “a good life” indicates an understanding of treatment objectives as being comprehensive and complex. Alf spoke about how his role involved helping juveniles not only to cope with addiction or behavioral problems but also to follow law and order, thus equipping them with the skills needed to adjust to society’s rules and expectations. The expression “a good life” is a subjective and normative utterance that makes it difficult to measure the outcome of a treatment in quantifiable terms.

Several informants highlighted that to capture the complexity encountered in their professional work, knowledge of treatment outcome should be related to the juveniles’ individual challenges and subjective experiences. In the focus group discussion, Nina identified drug abuse and behavioral deviance as aspects of a more complex totality: “They are sent here for substance abuse treatment, but we see that in many, many cases, substance abuse is the least of their problems. It is often merely a symptom of other challenges”. Nina used the word “symptom” to describe the relative impact of the drug problem in relation to other challenges in the juveniles’ lives. Nina’s description of the juveniles’ problems calls for other and more complex treatment objectives than merely “abstinence”, as emphasized by Olav.

Therese pointed to the challenges of finding reliable ways to document and legitimate professional work that diverges from the dominant policy:

Therese was concerned about the increased focus on short-term treatment in some of the new treatment programs, and she talked about treatment as a process. Her use of the word “process” indicates that she considers treatment to be a time-consuming activity rather than an activity that can be carried out in the short term. Following Therese’s line of reasoning, this also has consequences for how and when treatment results can be evaluated. Unlike the informants who spoke about outcomes being measured during and at the end of treatment, Therese spoke about having the patience to attain “results later”, which makes outcomes difficult to measure. When Therese mentioned “fighting the outside world,” she was drawing a distinction between her understanding of practice and the outside world. Therese described obtaining approval for her understanding of “later results” in professional practice to be a challenge.

The interview excerpts presented here show how the informants used certain words and expressions when talking about their understandings of knowledge and methods. Tensions were identified between complex goals versus specific goals, measurable objectives versus subjective valuations, treatment as a process versus treatment as a short-term intervention, and the outside world versus professional understandings. The patterns associated with the informants’ understandings of professional practice are interpreted here as being made possible by available and competing discourses.

The discourse of technoscience

The discourse of technoscience is the discourse that most clearly makes possible the ideas of evidence-based practice. The importance given to scientific knowledge and standardization corresponds well with the definitions of evidence-based practice that emphasize the use of best available research evidence in making decisions regarding individual patients. One such definition is that put forward by Sheldon, who described evidence-based practice in social care as “the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of service-users and carers” (as cited in Mullen & Streiner, 2006, p. 113). The use of RCT studies in evidence-based practice has been described as the gold standard in deriving knowledge about professional decisions (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). This type of research presupposes the comparison between a randomly selected experimental group and a control group. Several programs in the Norwegian child welfare system have been developed based on the findings of RCT studies (Backe-Hansen, 2009). As Knut pointed out, these programs usually have higher scores on treatment effectiveness. The belief in treatment effectiveness documented through RCT studies was also evident in the interview with Sigrid. Although she expressed ambivalence toward some aspects of the methodological framework, she seemed likely to accept the new methods if they were shown to be effective.

A unitary practice can be contrasted with a traditional view of social work wherein professional practices are characterized by inconsistency related to reflective and interpretative practices and are dominated by professional discretion and judgment (Barfoed & Jacobsson, 2012). The multiplicity of practices and the existence of a vague theoretical framework have been offered as one explanation why social workers in general have been described as occupying a low status in the professional hierarchy (McDonald, 2003; Molander & Terum, 2008). In an article from 2003, McDonald discusses the capacity of evidence-based practice as a strategy for promoting the goals of social work in the context of reforms inspired by New Public Management. This line of reasoning suggests that a unitary practice based on a scientific framework can contribute to reducing uncertainty in professional decisions and, hence, to increasing the status of the social work profession. Larson (1977) states that education and the employment of an accepted knowledge base can be strategic resources for increasing a profession’s status.

A belief in scientific knowledge embodies an important idea within the discourse of technoscience, which can accommodate demands for quality improvement from both the professionals themselves and the policymakers, hence making possible evidence-based practice in residential child care. A long history of insufficiency—as pointed out by Olav—seems to be a constitutive part of the discourse of technoscience, which opens up the field for the development of new approaches.

When I asked Olav about the evidence-based nature of the treatment method he had described, he mentioned that the method required major adjustment before implementation. This indicates that within the discourse of technoscience, constraints on evidence-based practice can be found if a narrow definition of evidence-based practice is applied. It is not enough to implement the new methods uncritically; they must also be adjusted. Hence, they must be subject to the professionals’ expertise. This is suitable within the wider definition of evidence-based practice, which also incorporates clinical expertise and the use of discretion (Backe-Hansen, 2009; Gilgun, 2005; Satterfield et al., 2009). The use of some discretion within standardized programs, as emphasized in the interview with Olav, shows that standardization does not necessarily reduce professional discretion or professional uncertainty. The opposite is also possible, as standardized programs can force professionals to make decisions constantly about when to use standardized methods or how to adjust them to particular work environments and clients.

The idea of clinical expertise within the discourse of technoscience is also illustrated in the interview with Knut. He used the term “success rate” to describe a statistically proven improvement in treatment outcome measured at evidence-based institutions. Although Knut was aware of this finding, he described his continued skepticism of the method’s effectiveness. Only when research evidence was combined with his practical experience did he express enthusiasm for the method.

In summary, the discourse of technoscience not only makes possible the use of current best research evidence and outcome measurement but also includes ideas concerning professional expertise. Based on this discussion, I argue that the discourse of technoscience has the potential to incorporate ideas of evidence-based practice. However, to account fully for the constraints related to professional ambivalence and the need for discretion within the methodological framework, a wide definition of evidence-based practice is needed.

The discourse of indeterminacy

Tensions between standardization and professional judgment in social work practice mark the frontiers of the two identified discourses. In the discourse of indeterminacy, professional judgment is interpreted as an important idea that involves the combination of formal knowledge and practical experience in professional practice. The discourse of indeterminacy allows for complex understandings of professional practice, regarding both the knowledge base and the objectives. The informants’ insights into certain situations—for example, Alf’s description of how to improve the overall life situations of juveniles and Nina’s comment that “substance abuse is often merely a symptom of other challenges”—call for both complex solutions and evaluation procedures .

The importance of autonomy and discretion when making professional judgments about individual juveniles was an oft-mentioned topic during the interviews. Generally, the informants who made use of the discourse of indeterminacy highlighted the variation in work experience and educational background of professionals working within residential child care in Norway, thereby underscoring the importance of professional autonomy and discretion (rather than the ideas of standardization).

The emphases on professional autonomy and discretion within the discourse of indeterminacy can be not only related to the nature of child welfare work (as illustrated in the interviews with Sigrid and Alf), but also interpreted as important elements in being a “professional” and in strengthening professional status. According to Freidson (2001), there are two crucial ideas underlying professionalism: the idea that certain work is so specialized that it needs special training and experience and the idea that certain tasks cannot be standardized or rationalized. The most notable aspect of Freidson’s theory is the equal importance placed on experienced-based knowledge and theoretical knowledge (Freidson, 2001). Jamous and Peloille (1970) argue that a profession’s status is dependent on the profession’s capacity to maintain “indeterminacy” in its practice. According to Jamous and Peloille, there will always exist an inverse relationship between technicality (routinization) and indeterminacy in professional work; hence, if one increases, the other will decrease.

The interview with Therese illuminates the tensions between standardization and professional judgment within professional practice. She expressed her concerns about the new methods and programs (e.g., the policy effort to standardize treatment periods) and called for counter-documentation instead. Within the discourse of indeterminacy, the standardization of treatment will be problematic because it leaves few possibilities for exercising professional judgment and making adjustments in fulfilling the needs of individual juveniles. Hence, if a narrow definition of evidence-based practice is used—implying the implementation of standardized methods and manuals derived from RCT studies—the discourse of indeterminacy will be a constraint on evidence-based residential child care. It can also be argued that the discourse of indeterminacy can make possible evidence-based residential child care if a wide definition of evidence-based practice—that is, one that integrates research evidence and professionals’ expertise—is considered.