From the real frontline: the unique contributions of mental health caregivers in Canadian foster homes.

Author:Piat, Myra
 
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Foster homes have existed in North America for the past 50 years, as many patients discharged from psychiatric hospitals were placed into these homes (Deci & Matrix, 1997; McCoin, 1985; Murphy, Penne, & Luchins, 1972; Trainor, Morrell-Bellai, Ballantyne, & Boydell, 1993). These community-based residences provide an important source of housing for people with mental health problems, many of whom have lived for years in institutional settings. Unlike most services for people with serious mental illness, which rely on professional staffing (that is, assertive community treatment), nonprofessional caregivers operate foster homes, which are indistinguishable from ordinary homes in the community.

Foster homes originated in Belgium where over 600 years ago families in Geel took people with mental illness into their homes (Carpenter, 1978; Linn, Klett, & Caffey, 1980; McCoin, 1983; Roosens, 1979). The concept of caring for someone in a natural family environment spread throughout Europe during the 1800s and was introduced in the United States in 1885 (Linn, 1981; Tuntiya, 2006). Although in recent years emphasis has shifted to more autonomous housing, such as supported housing, foster homes remain the oldest form of housing for people with serious mental illness (McCoin, 1985).

In Quebec, Canada, foster homes are also known as family-type residences, and are regulated by provincial jurisdiction (Bill 120, Law Respecting Health and Social Services; Government of Quebec). Canadian foster homes are analogous to the traditional adult foster home model in the United States, defined as three or more individuals in a residential care facility, small group home, or family-type setting under state regulation (Deci & Mattix, 1997). Yet adult foster care is only one alternative in a plethora of U.S. residential options for people with serious mental illness, including board and care homes (Morgan, Eckert, & Lyon, 1995); the Homeshare Program, where single clients are integrated into private homes (Rhoades & MacFarland, 1999); or supervised community residences (Getty, Perese, & Knab, 1998).Whereas Canadian foster homes are a public sector service, in the United States there is a trend toward the development of private, for-profit housing services under managed care (Byrne, 1999; Shera, 1996).

Although foster homes have flourished, in Canada they have not been viewed in a positive light. This poor image dates back to a study by Murphy et al. (1972) that criticized foster homes as places that merely provide room and board, are too structured and controlling, and do little to reintegrate people with serious mental illness into the community. Over time, foster care in Quebec has evolved from a "caretaking" to a "professional" model in which social workers play a key role. They supervise these homes, ensure quality service, and act as intermediaries between foster homes and the mental health system (Dorvil, Guttman, Ricard, & Villeneuve, 1997). Social workers are responsible for recruiting caregivers and for matching and placing clients in these homes. A social worker, serving as case manager, is assigned to each resident. According to Quebec Ministry of Health directives, an individual service plan for each resident must be developed collaboratively between a resident's social worker and caregiver.

Caregivers are nonprofessionals, mostly women, who house and care for up to nine residents, whom they are mandated to reintegrate into the community. They and their residents are initially strangers who contract to live together and, when successful, usually do so for many years (Douglas Hospital, 2006). The Quebec Ministry of Health stipulates that caregivers be paid a per diem for supporting people with serious mental illness in their homes. Caregiving offers advantages such as a flexible schedule, the possibility to be one's own boss, opportunities to learn, and the rewards of seeing good results with residents. Yet caregiving also involves a heavy commitment of time and energy. As round-the-clock workers, caregivers must be either present in the home or available by telephone. Caregivers must contend with illness-related issues, difficult resident behaviors and crises, and the stress of never "shutting off."

Nonprofessional caregiving is unique for five reasons: (1) foster home caregivers lack formal status or accreditation as mental health workers, (2) they have no job security (3) they have no official representation at a policy level, (4) they are not part of the hospital residential teams that oversee their work, and (5) they have no specific professional identity to guide them. Despite the acknowledged struggles between social workers and caregivers in achieving true partnerships, social workers are in a strong position to validate and formalize the position of caregivers in the mental health system (Plat, Ricard, Lesage, & Trottier, 2005).

Although current policy in both Canada and the United States favors more autonomous housing for people with serious mental illness (Kirby & Keon, 2006; Ministere de la Sante et des Service Sociaux [MSSS], 2006; President's New Freedom Commission on Mental Health, 2003; Rog, 2004), there is also consensus among mental health professionals that foster homes remain an important form of housing for people with serious mental illness. Thus, it is critical to examine caregiver perspectives on their work because little is known about how nonprofessional caregivers help their residents and how the help they provide compares with that of social workers. This article addresses this question in the context of a larger study on the helping relationship in Montreal foster homes. Findings presented in this study are part of a larger study funded by the Canadian Institutes of Health Research.

PREVIOUS RESEARCH

Professional versus informal helping is an important distinction in the literature and is pivotal to this study. Training around helping skills remains a central concern in social work curriculums (Brammer & MacDonald, 2003; Egan, 2002; Hepworth, Rooney, & Larsen, 1997). By definition, professional helping relationships are contractual and time-limited (Lapworth, Sills, & Fish, 2001) and purposeful and goaldirected (Brill, 1990). By contrast, informal helping, whether by family and friends of "help-seekers" or by employed caregivers, is viewed as less structured, more personal, and biased (Nystul, 2003).

Research on informal helping has focused primarily on family caregivers (Biegel, Sales, & Schultz, 1991; Lefley, 1996). Most studies emphasize the negative aspects of caregiving, including the following: stress and burden (Cook, Pickett, & Cohler, 1997; Karp & Tanarugsachock, 2000; Ricard, 1991; Song, Biegel, & Milligan, 1997; Tucker, Barker, & Gregoire, 1998) and coping strategies (Hatfield, 1987; Olshevski, Katz, & Knight, 1999; Stengard, 2002; Turnbull & Turnbull, 1988). Some researchers have begun to look at the positive aspects of caregiving (Chen & Greenberg, 2004). However, these studies focus on families and relatives of people with a mental illness, and foster home caregivers have not been included.

The literature on foster home caregivers is limited. The majority of caregivers are women with no professional training, who may have gained caregiving experience through raising their own families (Beatty & Sealy, 1980; Sickman & Dhooper, 1991). Other research has examined the characteristics of caregivers, their motivation, and their relationships with residents (Blaustein & Viek, 1987; Mousseau-Glaser, 1988; Rhoades & McFarland, 1999, 2000). These studies concluded that the majority of caregivers chose to operate a foster home for altruistic reasons rather than for profit. Moxley and Keefe (1988) reported on caregiver satisfaction with service providers and found that caregivers expected to be included in the multidisciplinary team.

Recent Canadian studies have explored life in the traditional adult foster home (Piat, Ricard, & Lesage, 2006), the helping relationship in foster homes (Piat, Ricard, & Bloom, 2000), and the caregiver's role and responsibility in the Canadian mental health system (Piat et al., 2005). Although social workers are heavily involved in the provision of residential services to mental health populations, there is no known research on how the work of foster home caregivers compares with that of social workers.

OBJECTIVES

The overall objective of this study was to explore the perspectives of foster home caregivers and their residents on the nature or type of help offered in Montreal foster homes. The viewpoints of caregivers and residents were elicited. The study emerged from the practice milieu. Social workers on the multidisciplinary teams first identified the need to better understand how nonprofessional caregivers help people with serious mental illness. Ultimately, it was hoped that new information would emerge that could be used to improve mental health professionals' interventions with caregivers and their residents. The findings presented in this article emerged from a question in the caregiver interviews on how the help they provide compares with the help provided by social workers.

METHOD

This qualitative study employed a naturalistic approach, as developed by Lincoln and Guba (1985). The objective of naturalistic inquiry is to "develop shared constructions that illuminate a particular context and provide working hypotheses for the investigation of others" (Erlandson, Harris, Skipper, & Allen, 1993, p. 45). We chose this approach as most appropriate to explore the helping dynamics that occur between foster home caregivers and residents.

The setting for the study included foster homes for people with serious mental illness supervised by two university-affiliated psychiatric hospitals mandated to provide community-based housing for mental health consumers. At the time of this study, there were 1,402 individuals living in 242 foster homes on the...

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