#53: Residential Care Should Be A Thoughtful First Choice For Some Kids, with Martha Holden

“Residential care is the last resort” sounds like a policy line, but it lands as a verdict on children and on the people who care for them. In this podcast conversation, Co-Director of the Residential Child Care Project at Cornell University, Martha Holden, and I push back on that idea and explore what happens when group care is treated as a serious, skilled, trauma-informed option rather than a dumping ground for system failures. 

We dig into what TCI is actually for: preventing harm during crisis, reducing power struggles, and helping staff respond to aggressive behaviour without re-traumatising kids. Then we zoom out to the bigger question, what guides the other 23 hours of the day? Martha explains why CARE was built as a foundational program model, how shared principles create congruence across shifts, and why consistency is not a “nice to have” when young people are highly sensitive to change and unpredictability. 

We also get practical about quality and accountability. Measuring residential care against foster care often ignores the reality that many young people arrive after multiple placement breakdowns, so we argue for outcomes that track change from each child’s starting point using effect sizes. 

If you care about residential child care, out-of-home care, workforce wellbeing, and what evidence-informed practice looks like on the ground, this conversation will sharpen your thinking. Subscribe, share it with a colleague, and leave a review. What would you stop doing tomorrow to lift the quality of care?

Martha's Bio:

Martha is a Senior Extension Associate with the Bronfenbrenner Center for Translational Research, and Co-Director of the Residential Child Care Project at Cornell University. Ms Holden is the author of the book, CARE: Creating Conditions for Change a program model for child caring agencies. She is the lead developer of the Therapeutic Crisis Intervention System (TCI) in use in children’s residential organizations since 1980, redeveloped for foster and adoptive parents in 1996, and redeveloped for schools in 2012. She provides technical assistance and training to residential child caring agencies, schools, juvenile justice programs, and child welfare organizations throughout the United States, Canada, the United Kingdom, Ireland, Australia, Spain, and Israel. In addition to her extensive experience in training, writing, and curriculum development, Ms Holden has served as an administrator overseeing the day-to-day operation of a residential treatment agency for children, including its education resources. 

During her career, Martha has been studying how to prevent the occurrence of institutional abuse and improve the quality of care for children in out of home placements through program development, training, technical assistance, and influencing organizational culture.

Links:

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Podcast Blog Site: https://thesecurestartpodcast.com/

Disclaimer: Information reported by guests of this podcast is assumed to be accurate as stated. Podcast owner Colby Pearce is not responsible for any error of facts presented by podcast guests. In addition, unless otherwise specified, opinions expressed by guests of this podcast may not reflect those of the podcast owner, Colby Pearce. Finally, all references to case examples are anonymised to the extent that the actual case could not be identified, or are fictional but based on real-life examples for illustrative purposes.

Transcript

Welcome And Why Models Matter

Colby 0:00

Welcome to the Secure Start podcast brought to you by the Secure Start Aura apps supporting trauma-informed care and practice at home and in school.

Martha 0:17

People would say that TCI was their program model, which was a little horrifying because it's a crisis prevention and management system, and not everything is a crisis. So you want people to have a working model to handle all the other times of the day. What's even kind of a bigger program for us now is a few years ago we adapted TCI for schools because school people kept showing up in our TCI for residential because same kids, same problems. I find it disturbing when people present it as last resort for a number of reasons. And one is we should not be placing children with that as even an option. When children are not able, for whatever reason, to stay with their family, and we need to do something as drastic as remove them from their family. We should be doing a really, really good assessment of what this child, where will this child be able to continue to grow and develop and thrive? And that for some children, straight out the gate, might be group care. Kids hear this, right? Kids who are living in group care. I mean the last resort. I mean, what you you failed your way into residential care, is what they're saying. And that puts so much on that child. What staff wants to go work in somewhere that's a last resort? So you're kind of dooming the whole sector. Quality has to do with everybody having kind of the same working model. And it should be based on a set of some sort of evidence-informed principles or standards. If we're going to measure anything at all as an outcome, are you going to measure what change has occurred? With that, I everybody's looking for some quick inexpensive fix to big complex problems. And I think, well, I wish there were, but I haven't found it yet.

Meet Martha Holden At Cornell

Colby 2:29

Welcome to the Secure Start Podcast. I'm Colby Pearce, and joining me for this episode is another leading figure in the worldwide residential care community. Before I introduce my guests, I'd just like to acknowledge the traditional custodians of the lands that I come to you from, the Kaurna people of the Adelaide Plains, and acknowledge the continuing connection the living Kaurna people feel to land, waters, culture, and community. I'd also like to pay my respects to their elders, past, present, and emerging. My guest this episode is Martha Holden. Martha is a senior extension associate with the Bronfon Brenner Centre for Translational Research and co-director of the Residential Child Care Project at Cornell University. Martha is the author of the book Care, Creating Conditions for Change, a program model for child caring agencies. She is the lead developer of the therapeutic crisis intervention system or TCI in use in children's residential organisations since 1980, redeveloped for foster and adoptive parents in 1996, and redeveloped again for schools in 2012. Martha provides technical assistance and training to residential childcaring agencies, schools, juvenile justice programs, and child welfare organisations throughout the United States, Canada, the United Kingdom, Ireland, Australia, Spain, and Israel. In addition to her extensive experience in training, writing and curriculum development, Martha has served as an administrator, overseeing the day-to-day operation of a residential treatment agency for children, including its education resources. Throughout her career, Martha has been studying how to prevent the occurrence of institutional abuse and improve the quality of care for children in out-of-home placements through program development, training, technical assistance, and influencing organizational culture. I hope you enjoy our conversation. So, Martha Holden, welcome to the Secure Start podcast. It's a real privilege to have you here. Yes, yes. And I look, I've known um about you and your work for some time now, and uh I'm really keen um to share the story of the work that you do on this uh platform. And uh so likewise very much looking forward to to this conversation. And uh I thought maybe we would just start with uh if you could tell us a little bit about um what you do and how you came to the work that you do.

Career Path Into Group Care

Martha 5:51

Okay, well, um I work at the Residential Childcare Project at Cornell University, um, and I have been working there for as now it's the majority of my career. I've been there uh full-time uh since 1990, um, where I was brought in to manage the project that was called therapeutic crisis intervention. Um I came to that from I had been working uh for about 10 years at a residential treatment facility. Um and before that I was a child protective service worker for a bit. Um and came to this work, I think uh for some reason I was very much attracted to the young people uh who were really struggling in foster care and uh started doing a little work with the group home and saw the possibility for children who were just not making it in a traditional family situation. Um and that basically led me to uh deeper and deeper into what are the benefits or what could be the benefits of really good therapeutic group care. Um so when I had an opportunity to do some work at Cornell University, which was developing programs and disseminating programs uh for out-of-home care, I jumped at the chance and it's been a wonderful place uh to do that work.

Colby 7:20

Yeah, wow. And you you as you say, you've been there since 1990. So what's that, 36 years? Sorry, sorry to mention that.

Martha 7:31

I I was barely uh, you know, out of uh high school at that time. Yes, probably.

Colby 7:39

So uh I guess uh you would have had um there would be some pretty significant influences, not least of which what you just mentioned, um wanting to look at how to do things better in a different way that may ultimately be better for children who are struggling in a traditional foster care arrangement. Um I'm wondering what influenced your perhaps more from a professional and and the bodies of work, bodies of theory that influenced the work that you have done over this past several decades.

Influences And The Everyday Hours

Martha 8:16

Um, yeah, so many, actually. Um I don't know where to begin, but certainly a lot of it is the the children and their families. I think that was a big influence on me. But when I look to kind of the gurus in the field, um certainly Al Trishman, who I had the honor of meeting and spending a few days with, he was uh he was a powerful force and uh really had me, I think, focusing on the 24, 23 hours, the other 23 hours.

Colby 8:48

The other 23, yeah.

Martha 8:49

But what just happens in the in all the everyday and ordinary moments of group care. Also, Henry Mayer, same thing, um, uh was privileged to um know him a bit and and be in some of his workshops and seminars. Um uh reading the works of Fritz Radel, uh very much uh the whole generation of people who really uh saw the power of a good therapeutic group setting. Uh Jim Whitaker, Jim Anglin, uh those are still a force in my life. Um I think to really, though, do some of the development work, I have to say um big influence on me was working with my uh my life and work partner, my husband, Jack, when we met at the residential treatment facility where we worked. And when we left there, we had the opportunity to take some young people on camps. They were out of group care uh for a week. And we would design these weeks based on what we thought would be a good way to be with children. So I think a lot of the ideas that I've been able to develop at my work at Cornell came from working with a couple of other adults, but with groups of young people, um, just seeing how we could have them have a week that was not only fun, but something that was therapeutic and educational for them.

Colby 10:23

Yeah, yeah. And you um in the in those years that you've been associated with um the Cornell program, you you um have worked on and with others on the therapeutic crisis intervention or TCI, which should be uh which is likely to be quite well known amongst listeners of this podcast who work in residential care in particular, uh, and also the the care the care framework or the care model. Um and I'm wondering if you might just just for those who who don't uh are not O Fay with them, maybe just give a little bit of a summary of of each of those and and what um what are the main kind of influences over how they've how they are, how they've they've manifested, manifested as programs.

TCI And Preventing Harm In Crisis

Martha 11:16

Right. Well, therapeutic uh crisis intervention was actually how I was introduced to the work at Cornell um because uh when I was working in residential treatment, I was uh seeking some sort of system to help um our staff handle aggressive behavior. We were working with adolescent boys and we had a lot of aggressive behavior um in our units. And so I started searching for different uh trainings or programs and came across a therapeutic crisis intervention at Cornell, which was just in its early stages, and uh went and met the developers at a conference, and actually I became a consultant with Cornell, and this was oh, I think early 80s. So um I helped them uh do a first revision with the curriculum, and eventually that's what led me to uh take the job of managing that program. I think it's based on solid crisis theory. Um, it's been trauma-informed before we talked about being trauma-informed, um, and its focus was actually on preventing child abuse in institutions. Um, it was developed in order to help staff deal with aggressive behavior without getting into power struggles and actually re-traumatizing or even abusing children. Um I think the the most wonderful thing about TCI is it's it was started, we started disseminating it in the early 80s and it's still here. It's in its seventh edition. And I think what keeps it relevant and strong is we work with uh partner agencies, agencies who have been using uh the system for so long, and as well as our own research and evaluation and looking to the field and continually updating it and um revising it and working um hand in hand the kind of translational research we do at the center to keep it honest and useful in the field. Um so um that's a program I'm incredibly proud of and and its ability to stay relevant in the field. Um through that work, I think is how we ended up deciding.

Why CARE Became The Foundation

Martha 13:42

This was about 2001 or two, uh, to see if we could develop a foundational program model for care. What we were learning were uh people would say that TCI was their program model, which was a little horrifying because it's a crisis prevention and management system and not everything is a crisis. So you want um you want people to have uh a working model to handle all the other times of the day. So we started looking at research and getting some partner agencies uh to work with us to take a look as if there's enough evidence out there on what works in out-home care and group care to actually develop a program model. And we found that there was. Um so we partnered with about 15 agencies in North and South Carolina to basically pilot something. Uh they were TCI agencies, so there was some trust there that uh we wouldn't give them something that was going to cause harm first. But um, so as we went through that process, we got very excited thinking, wow, we're on to something here. This is a good foundation to provide therapeutic uh residential care. And so that now has been going. Um I think after the field test and the pilot, um, it was really launched around 2009. And is in its third edition now. So the process of continually working to keep it updated and relevant and effective.

Colby 15:26

Yes, yes. And my understanding is that there's been some pretty encouraging research done in relation to the care program in particular.

Martha 15:37

Yeah. Um this is one of those times where uh we did get some foundation money. I have to, my hat's off to the Duke Foundation and in the Carolinas. Uh they had worked with us in the Carolinas and implementing TCI and agencies, and they were excited about this and helped give us some development money to get it started, and then gave us a rather loud, a large grant to actually see if we could evidence it. So we went into the development with the idea of okay, we're gonna start out with the idea of evaluating it as we go along, in hopes that if it did provide uh good outcomes for children and organizations, that we could evidence it and and basically get it listed as an evidence-based program. Um we're long timers at Cordell, so we looked into it and thought that generally with that kind of a massive program, it takes about 17 years to accomplish that. I mean, it takes about four years to implement it. Um But we were we were eager to get going and we actually managed to get enough evidence that it was improving um some different aspects of the children's uh experience in care and how they responded. Um we were it was evidenced in um 20 and 17, so uh we beat the odds there a little bit.

Colby 17:10

Yeah.

Martha 17:11

Um so we were we're very excited about that.

Evidence Building And Anglin’s Impact

Colby 17:16

And I've had Jim Anglin on the podcast a couple of episodes ago, and uh I wonder if you wouldn't mind just just saying a few words about Jim's work and and how that has um contributed to the work that you've you've done at Cornell.

Martha 17:33

Yeah, I'd love to. Jim was um when we were thinking about um developing a program model uh, um I was speaking to my that time boss Michael Nuno, and he and I were going back and forth, back and forth as to whether we should attempt this. And honestly, we were a little bit skeptical that there was enough evidence in the field that we could draw on to do this with confidence. And he uh was in a at a conference in Scotland and heard Jim Englin speak and got his book, which had only been out, I think, a couple, two or three years at that point. Yeah, pain, normality, and the struggle for congruence, which I still kid Jim about is uh not a great name for a book.

Colby 18:20

No, it's a bit of a mouthful.

Martha 18:23

But Michael uh came back very excited and said, You've got to uh get a hold of this, uh Dr. Anglin. And he told me the book, and I'm like, really? Because the title was a little off-putting. And he said, Yes. And I said, Well, why would why would somebody speak to me? You know, he's an author and scholar, and he said, just call him. He's he's like us, he's one of us. So I did, and it has been such a great relationship. Jim has been on the care journey with us from the very beginning. Um, his work, his his research um gave us uh some underpinnings that gave us some evidence straight out of what would be good for uh kids and and group care. And uh he's also done some evaluation of our implementation model. Um, I was just at a conference with him in Canada last week where um he's speaking about uh residential care, and he's still a major influence for us. So um, and on me. He's been he's certainly been a great colleague and offered me a lot of opportunities um in the field. So he's pretty wonderful.

Colby 19:34

He is, he is. I've like like you, I sometimes wonder if people will talk to me. Well, like you, many years ago, I should say, for me contemporaneously. Um, and then I approach people and they're like, Oh yeah, thought you might have got to me by now.

Martha 19:53

Exactly.

Colby 19:54

I feel like you have to build up a bit. Yeah.

Martha 19:56

It is why would somebody return my call, right?

Colby 20:00

And Jim has been, I mean, he it was very difficult to finally get hold of him, but he's been nothing but encouraging since. Yeah.

Martha 20:09

Yeah, and I think he has great affection for our um our team and the program. And often says, he may have said it on your podcast, I don't know, but it's not often a researcher actually gets to see the work that he's done actually make a difference in the field. And that's what our project is all about, right? Translating research and theory into practice. So it's been a perfect marriage, actually.

Colby 20:33

Yeah. Wow.

Global Reach And School Adaptation

Colby 20:35

Um, you mentioned the Carolinas as being uh places where TCI was already um being rolled out and delivered. Um, I'm just I'm wondering about what has been the reach of the Cornell program in terms of the delivery of TCI and/or care. I mean, I of course I know of places where where either one or both have been rolled out. Um, but maybe just tell us a little bit about what has been the reach of those programs.

Martha 21:06

Um well, that certainly is international. I will say we're not a large group. So um, and because we're housed in a university and and I work on the residential childcare project, but it's part of the Bronfen-Brenner Center for Translational Research, which is a department in in one of the colleges at Cornell. So I think we have the luxury of not, we're not for profit, and we have a dual mission of research and extension. So um uh we have no desire to take over the world or be large. We have a desire to uh take disseminate good programs into the field, but can partner with our community partners to evaluate and do research at the same time. So um we've had The opportunity to do a lot of international work nationally within the US, I would say TCI. There are organizations uh in in almost every state, I would say, that uses TCI. And and what's even kind of a bigger program for us now is a few years ago we adapted TCI for schools because school people kept showing up in our TCI for residential because same kids, same problems. So we developed that program. So now I would say uh TCI is in schools all over the US also. Um, Canada, we've been working in Canada, oh, I think since probably the late 1880s with TCI. So there's a lot of programs there. Australia, UK, Ireland, um, Israel, we have programs um in and in South Korea, and just random countries come to us and Russia for a while. I'm not sure what's going on there now, but uh, we had some programs in Russia. Um one of the things that we try and do is when we um go to another country, is we partner with an organization in that country who then um provides local support and helps uh do the contextualization of whatever we're doing so it fits with the culture, the language sometimes when things need to be translated, but also just the kind of political and economic and social realities of the organizations that are taking it on. So we have uh agencies that are disseminating um TCI in in Europe, in Canada, in Israel, in Australia, and um in we don't have anyone right yet in South Korea. We've just been there a few times, but um and then care has is a the same and a little different. We also have uh we have uh care agencies now in Canada, US, Australia, Ireland, um, Wales, and Spain and Taiwan. So it's kind of word of mouth. Um people uh hear about it or read about it. We publish quite a bit, so and contact us. And if we can work out an arrangement where there can be local support and ongoing dissemination, then we um seriously uh set up programs in those countries.

Colby 24:42

Yeah, yeah. And I'm wondering with such a diverse um implementation worldwide, I'm wondering if you have time to reflect on differences that exist, I guess, between the jurisdictions in which you either care or TCI or both are delivered, uh, in terms of just how they um manage residential child care and their thoughts about it.

How Systems Differ By Country

Martha 25:16

Um absolutely. Um and actually I love the international work, and part of it is working in those different uh contexts and seeing how the programs might fit um with different types of uh group care. Yeah, I think um there are quite a bit of differences. What's similar are the children, young people, families, and the caregivers. There are more similarities to that aspect of the work. Um I think the differences very often are um, well, size. I think the and especially in Australia, they do residential care, small community group homes. They used to have the more campus-based or residential care and treatment, but they really don't have that anymore. Um UK would tend to have mostly smaller uh groups, uh, community homes. Uh, Canada is a mixture of both. And we have both in the US too, but you wouldn't find the larger residential. And then in Taiwan, South Korea, they have large, uh sometimes even dormitory still type residential homes. So it's a lot of differences in just the way it's constructed. Um, and a lot is driven by the way they're funded and regulated. That's can be very different country to country, and be very difficult for people to, depending on how they're funded, plan, develop expertise, uh commit to um like uh implementing a program model, uh lot of different realities that they're working in.

Colby 26:56

Yeah, my my most recent past guest, Tanya Raboo, um talked about residential care or group homes, group care as being the predominant um approach, I get to the um care of children and young people who couldn't be safely cared for at home. And yeah, and then um and referred to referenced other European jurisdictions as well where that that is the case, which as you as you point out is very different to how residential care is delivered here in Australia, for example, and in many other jurisdictions. Um I there's a I I have I think this is probably a good time then to perhaps raise the question about um or bring up the topic of residential care as an option of last resort.

The Damage Of “Last Resort” Framing

Martha 27:48

Um that we know I'm not gonna like that.

Colby 27:52

No, no, well that well I think I think there there are there are loud voices, there are there are strong voices in many jurisdictions, including here in Australia, who um who do speak in a in a very pejorative way about residential care. And and it's seen as not only the option of last resort and the most expensive form of care and um but it's spoken of as as if it harms children.

Martha 28:24

Yeah.

Colby 28:25

And um I've been working in the sector here in for more than 30 years here in South Australia, and a couple of things that stand out for me is that not all residential care is the same, and it's not even the same experience across young people in in residential care. Um and I don't want to hog the hog the floor, but I know you have I know you have similar thoughts about this, so please. Yeah, there are there are there are a group of children for whom residential care sh should be the option of first resort.

Martha 29:06

Right, right. I yeah, I I find it um I I find it disturbing when people present it um as last resort um for a number of reasons. And one is um we should not be placing children uh with that as even an option. I mean, it's I children when children are not able uh for whatever reason to stay with their family, and we need to do something as drastic as remove them from their family, we should be doing a really, really good assessment of what this child, where will this child be able to continue to grow and develop and thrive. And that for some children, straight out the gate, might be group care. Um, for others, it could be kinship care. For others, it could be foster care. Maybe some children need like an emergency psychiatric evaluation. I mean, it could be any number of things, but to say this child can't be at home, go find a foster home because that's the least restrictive, I think is not uh I certainly wouldn't want a child of mine to be treated that way. I if they're taking a child away from me, they better know exactly what they're doing and why and where this child is going to do better than staying with their family. Um, it's also insulting to the child. I mean, I kids hear this, right? Kids who are living in group care. I'm in the last resort. I mean, what you've you've failed your way into residential care is what they're saying. And it that puts so much on that child. And then when that gets heard, what staff wants to go work in somewhere that's a last resort? So you're kind of dooming the whole sector to being a bad place to work and a bad place to live. And I don't think that's true at all. As many children, I think children can be harmed in any setting in their own family and foster care and kinship care and group care. So we should be working at making sure all of those are quality settings.

Colby 31:16

Yeah.

Martha 31:16

And then place children where the where they where they get what they need at that time.

Colby 31:22

Yeah, yeah. Yeah, I always get a bit of a rise out of people who are in a position to influence the care that is delivered uh to our children and young people speak in this way about residential care, uh, not least because there actually there are actually children in residential care at this time. And and and they, you know, and in my own jurisdiction, they tried to get rid of it. And and they can't because it is it is a valid option. There are there are children who who just do not cope in a family-based care environment. And who don't and there are there are older children who do not want to be in a family-based care environment. They have a family.

Martha 32:11

Right. They have a family, or they've already been through several families and they just don't want to do it again.

Colby 32:17

Yeah. Yeah. Yeah.

Martha 32:18

Yeah. I think it's I I think it's problematic uh that uh in the way that it continually gets um spoken about that way. Um people their group care has been around forever, and I don't think it's going away. And and we just keep the other thing that occurs to me, and I've actually, believe it or not, said this to um agency personnel and agencies that actually place children who say things like that, said, You you're responsible for this child's well-being, and you're telling me you're okay placing this child in a in a home where you think it's a last resort and not a good place for children. I mean all parts of the system, I think, are are um behaving badly when they speak about that, because they're not taking responsibility for working in the best interests of the child at that point.

Colby 33:10

Yeah. Probably the worst thing I've ever seen was a social media post by a government minister talking about pro new program that was funded to save children from residential care. And you just you just think, oh I I also think of the staff. You've meant you mentioned the staff, but I I do think of the staff insinuating that the care is of so such low quality that we need to save children from it. Like how do you is that the best how you get the best out of people in the sector? I don't think so. But yeah. I think um so you so and and it is a it's a diverse um there is diversity in children's residential care as there is in other forms of care as well. Diversity of of service provision or care provision and and diversity of experience for young people. Um I do wonder what you would say. Yeah, and I do wonder what you would say are some of the the key ingredients of quality residential childcare.

Defining Quality And Measuring Change

Martha 34:27

It's interesting. I just came back from a conference where the topic was quality, and we had a lot of conversations about what is quality. Um and I think I came away with that um with a lot of different thoughts, but I think at the end of the day or at the core of it, it's providing a quality experience for young people and their families. And by that I mean an experience in which they feel cared for and cared about, where they have opportunities to um learn, to meet developmental tasks, where they um are surrounded by uh adults who are skilled at um developing good relationships, at knowing how to help children develop skills, um, at engaging um in activities with young people so that it provides as much as possible an environment in which children um aren't overly stressed, have the space to um heal um and to re-engage in activities and relationships with friends, with family, um, and more or less uh be able to have a childhood in a way that they haven't been able to do. Having said that, uh we talked about how do you measure that, right? And that's a little tough, but we came to the point that um not everything you can count is important, and sometimes what's important you can't count, but that um there are things you can look at to measure good outcomes. Um, but I think quality has to do with um everybody having uh kind of the same um working model so that there's provides that um collective developmental experience for children.

Colby 36:34

Um the congruence that Jim refers to.

Martha 36:37

Jim's congruence, absolutely, that we're always struggling for congruence. And it should be based on a set of some sort of evidence-informed principles or standards. Yeah.

Colby 36:48

You mentioned research and evaluation, and it it occurs to me that one of one of the um the difficulties with evaluating residential care is that the children who who find their way there in many jurisdictions have already been through a number of family-based placements. Uh where and it's my contention, echoed by many of the people that I speak to on this podcast, that though, that that the repeated breakdown of family-based care arrangements for this young people, these young people, does massive harm to them. So we we're ending up with an out a situation where they've where children have been harmed through repeated family-based placement breakdowns, they end up in well, they've into in residential care, last resort. And then and then we evaluate outcomes against foster care.

Martha 37:52

Yeah, well, I think we measure the wrong things. Um, I I mean, one of the things I believe that a lot of times people um have a misunderstanding of what, if we want to call it business we're in, because in some ways um there is a contract and an assumption there. And I think what we're trying to do is we're trying to create a uh condition so that children and families can change, can grow. And so if we're going to use some sort of measure, I think you measure how much change has there been. So everybody has a different starting point. And can you move them from that starting point to a better outcome? Um, I read this article, it's been years and years ago, that addressed the the same thing, but I think it was about dentistry where you can't compare these two practices where somebody is dealing in an area where children don't have dental care, they don't, or adults, anyone have good dental hygiene or care or fluoride in their water or whatever, against somewhere where they've had perfect dental hair, because dental care, because the one dentist is dealing with a mouthful of cavities and the other isn't. So you can't compare those kind of outcomes. And it's the same thing here. So I'm more about can we measure, if we're going to measure anything at all as an outcome, are you gonna measure what change has occurred, not compare it uh to a profit?

Colby 39:25

Yes, uh uh, and I guess um we refer to them as effect sizes. So yeah, the the the amount, which basically is the the change from point A to point B for each individual and the magnitude of that uh aggregated across a group. Yeah.

Martha 39:43

Right.

Colby 39:44

Yeah. So any any research that just that I guess that doesn't do that, that just simply says, well, this is these are the the outcomes of care leavers who grew up predominantly in a family-based care environment, and this is the outcomes for those who grew up in a residential child care environment, and doesn't look at effect sizes, just looks at those outcomes. It really, really doesn't provide anything uh really useful for understanding the difference between foster care or family-based care and residential child care.

Martha 40:24

No, I I don't you wouldn't do that anywhere else. You wouldn't compare um outcomes between totally different kinds of uh services. It doesn't make sense that and this is I think also where things are confusing with just residential care itself. I mean, there's so many different varieties, just lumping them all together isn't that useful either.

Colby 40:47

Yeah.

Martha 40:47

Um but what I think I think what happens is instead of uh taking a look at outcomes to find out what works, hey, you know, what's working here that we can transfer over here and looking more what's inside that black box, you know, what's making what work, and how do we get this good outcome here so that we can share it across the field? It's a competition. It's it's based on on this um thought that we need to we need to show uh that residential care doesn't work and foster care does work, so we can just use this. And and that again, I don't think that's a good use necessarily of research, at least not research that promotes good practice.

Colby 41:30

Yeah. Being a clinical psychologist, an analogous area is has been across my career, comparisons that are made between cognitive behavioral therapy and psychodynamic and psychoanalytic approaches to psychotherapy, where um psychodynamic and psychoanalytic have been seen to be you know expensive, labor-intensive, long, you know, long-term and cognitive behavior therapy relatively inexpensive, goal-focused, short terms, easy to research, shows demonstrable outcomes. And for much of my career, and still to this day it is the case in terms of funding arrangements, at least here in Australia, CBT is seen as the gold standard approach until people started to look at effect sizes. And and and even with brief psychodynamic approaches, those effect sizes are comparable, if not better, than than CBT. And in particular, the longer-term outcomes are really good for the more dynamic approach. So yeah, it's interesting how I think we we fall into these very when I say we, I say as a society, perhaps as funders, they fall into these very uh making decisions on the base of these really um problematic assumptions, analyses of of of the you know, the of the analysis of this this approach versus that approach. And um of course in everything in life and humans, it's much more complicated.

Martha 43:19

Absolutely.

Residential Care Versus Treatment Models

Martha 43:20

Yes, there's a complexity there that doesn't uh uh really work well with that. I everybody's looking for some quick inexpensive fix to big complex problems. And um uh I think well, I wish there were, but I haven't found it yet.

Colby 43:38

No, no. So um I guess another thing that has uh come up in the course of my uh my uh podcast interviews has uh has been, and it's been mentioned a number of times, is is um treatment, residential care or residential treatment and residential. Care and um and I'm aware of some differences across jurisdictions in terms of how residential care is delivered, you know, a care with a care focus or with a treatment focus. I wonder if that's something that you uh have some thoughts about.

Martha 44:21

Well, uh for instance, in most states in the US, it's a way to it's a funding right issue and a staffing issue, and and what services are provided. So we would have residential care, we would have residential treatment, um, and residential treatment would um probably have additional staffing and provide actual treatments like could be um counseling or therapy, it could be drug treatment, it could be a range of treatments that um have been identified as needed uh for specific children. Um but I think uh my experience in Australia, and you have much more experience in Australia than I do, but you generally don't provide that kind of system. You provide care, and then if child needs certain treatments, they go to the community to get those treatments. So um and I'm I'm not convinced one is um better than the other. I think um residential treatment in the US, when you there's an economy of size, this is when you're going to get larger programs that then can provide the specialized school on the campus, has therapists available, psychologists available, psychiatrists available, um, can do different kinds of treatment groups and make it um it's still expensive, but probably there is some uh cost savings in doing that. Um of course then it becomes it's a it it's a a larger program, which for some children I think works very well. Um the problems I've seen if you're just trying to do that sometimes in the community is waiting lists. I mean, sometimes it's very difficult to get these children who really do need specialized treatment services into community programs. Yeah. Um but um at at the at the core of it, I think all of them, regardless of what we label them, need to be good therapeutic residential care. I think that's kind of the foundation, and then you can build on that or or not.

Colby 46:34

Yeah, I think the treatment aspect of it probably sits in people's minds more in those secure care uh secure residential care arrangements. I would have thought it's not something we have here in South Australia, a proposal to look into that um via review process that happened a number of years ago didn't support that happening. Um I know I do work in Ireland, for example, they have secure care in Ireland. Um, but they I know they also have um some of the some of the placement practices are differentiated along the lines of therapeutic care uh uh or and a higher level of care, so more like treatment care versus almost care as usual, I guess, within with in in the sense. So and and I know, for example, that um um that your care, the Cornell care model is is uh seen as being a model and an approach, a pa a package for that um that is can be used or is used for for children who require a higher level of care, higher level of therapeutic care.

Martha 48:05

Right. I think what our uh the care model is is designed to be a foundational model. Um so that um and we have um organizations that are you would say group home community group homes, uh house parent models also in the community to um more just group group care to residential care to residential treatment care. Um so it's a range, you know, emergency care. So it's it's designed to um, as Al Trishman say, give that unifying something to organizations or that congruence about uh uh designing all your interactions and programs and activities according to these six evidence-informed principles that are pretty much human principles. Um so I think we've discovered even when we thought, like we've implemented care in uh uh juvenile jails and and were very hesitant about that, but you know, gave it a shot and it improved. It absolutely improved the day-to-day care of those uh young people in a very secure and non-treatment um uh setting. Uh but again, you'd have to look at the effect, right? They started from a very low place and got higher, but would I compare them to what happens in a residential treatment setting? No. Um, but I think it's designed to make whatever care that you're providing therapeutic and um developmentally appropriate so that it's for children, so they have opportunities to grow and develop.

Colby 49:53

Yes, it's I I guess what I'm um from at least from my point of view foundational shouldn't be confused as being the you necessarily the first step uh and um um and uh and in some way um that there is there is the imputation that there are big there's bigger and better out there. You know, you start with this and then you move on to this. And then if you know what I mean.

Martha 50:24

Well, okay, only if you need to. I think it it provides that um uh operating uh model for folks.

Colby 51:00

And I actually think that's the most important thing to do.

Martha 51:03

Well, I do well I do too. I'm sure that's no surprise, but I think you've got to, I don't think kids can get engaged in school, in treatment, in whatever has been, you know, assessed that they need unless they're feeling safe, they've got uh adults around them who are their advocates, their you know models, their um supporters, um, and and that they have uh access to family and community. I mean, I think you have to provide that kind of setting, whether it's in group care or foster care or any. I mean, that's when children can engage in the kind of things that are going to help them develop along more normal developmental trajectories, which is what I think we hope for for the kids in care.

Colby 51:54

Yeah, yeah. And I'll I also think that um foundational approaches tend to um be just you know understanding human nature and and and how we respond to change and how we change our um approach to life and roles and relationships. Um it's uh it's a it's it's a different proposition to to get people to um implement a an approach that is not foundational, if you like, is is perhaps some might say or see it as being more sophisticated, requiring requiring a much more cerebral approach to to the role. And my my view is that um you are it is very hard to get to get staff or carers more generally to um to implement something like that in the first place. And even if you could get them to implement it, it's hard to get them to keep doing it over time. And so what you end up doing is shaking up a system that uh that is servicing children who are highly sensitive to inconsistencies. Uh I I often refer to inconsistency as the primary trauma trigger. Whereas on the other hand, um when you when you implement or you roll out a program of care that is foundational, you know, almost unarguable, these are the these are the general principles we want you to follow. Like who can argue against them? These are the aspects of care that you've probably experienced, you've probably you've undoubtedly experienced, and you've undoubtedly delivered. Yeah, we just want to organize it a bit more. Um you that they're the they're the approaches that you're most likely to get the best compliance or adherence to the pro to the program. Um and and because of the nature of the children, the best outcomes as well.

Martha 54:15

Yeah, yeah, it has to resonate with folks. It has to it work for them.

Colby 54:20

Yeah, yeah, absolutely. So Martha, what what's what's the future hold for the Cornell program and for Martha Holden?

Fidelity, Context, And What Comes Next

Martha 54:33

Well, I think uh well, we're it's um it's a little stressful times right now um in um uh in the US at least. So I think um right now we're really taking this time, I think, and putting it to good use with um doing a lot of uh reviewing um and updating a lot of our programs, um, designing some future possibilities for more evaluation and research that we can get excited about, um, and really looking for international collaborations. Um, the international work is such a small field. Residential care is a very small field. And um because of that, I think there's a lot of opportunity in there to collaborate uh with like-minded folks around the world. So um we're very keen to continue our international work with international universities and and um organizations. Um I think um I'm I'm very much interested in uh taking a look at right now maintaining um program models. You know, I think we're gotten really good at implementing them, helping organizations uh put them in place. Um, and we're doing pretty well with uh the organizations that we worked with and helping them sustain them. But I think that is an area that is a little bit under-researched. And um, I don't think we I think we have a lot to learn yet about how does an organization, once they've made this huge investment and commitment to uh put therapeutic crisis intervention or the care model or any model in place, how do they hold it with fidelity and keep everyone working in the same direction? So that's something that we're really hoping to continue uh working on.

Colby 56:31

Again, we come back to the struggle for congruence.

Martha 56:35

Absolutely.

Colby 56:36

And fidelity was the word that I was trying, you know, in my in my a few minutes ago, my my soapbox um speech there about about change processes is that yeah, it is fidel. Fidelity was a word on the tip of my tongue that I couldn't quite um spit out and read, as my mum would say. Um, yeah, the the fidelity is an issue, isn't it?

Martha 57:00

That um well, fidelity with I mean it I what I think is very exciting about our work is we do really partner with our the organizations who use our models. And I think part of the uh beauty of what we've been able to do with the care model is um keep the core principles and keep integrity to the model and the elements that have been evidenced as contributing to positive outcomes in different settings in different countries and different cultures by doing the kind of adaptation or contextualization. We're not adapting the model, but we're contextualizing it based on the type of children, serve the type of staffing they have, of the culture in which they're working. And that's been um exciting work. And so then you're looking at um sustaining models with fidelity based on the cultural context in which you're working. Um, so we're looking for those key elements across the world that help these organizations hold the model uh so that it maintains its effectiveness.

Final Reflections And Thanks

Colby 58:17

Yeah, yeah, wonderful. Well, Martha, thank you very much. Um I spoke earlier about um being surprised, uh, you know, kind of putting off approaching certain people. So I I I'm glad I I was very glad to hear that you were happy to come on the podcast. And uh um yeah, and I I wish you well in on those future endeavors that you you referenced there.

Speaker 7 58:44

Well, thank you. It's been a pleasure. It's been nice talking to you, Colby.