Building Life Around the Foster Home vs. Moving On: The Competing Needs of People Living in Foster Homes

Abstract

Amid the current shift toward more autonomous housing for mental health consumers, people living in psychiatric foster homes in Montreal, Canada articulated complex concerns over what type of housing would best meet their present and future needs. Semi structured interviews were conducted with 33 residents. Consumers describe the tensions associated with foster home life. Two overall competing needs emerged: the need to build their lives around the foster home and the need to build life beyond the foster home. Residents describe their need for security and support versus their need for greater personal autonomy, the dilemmas associated with communal living, and their struggle to envisage a positive future. Housing arrangements, as well as the relationships and patterns of support that develop there, are critically important for residents. Mental health professionals mandated to dismantle foster homes for more autonomous housing need to take this reality into account.

Introduction

This article reports findings on the needs of foster home residents in relation to their living situation. Amid the current debate over which housing options best enhance the life prospects of mental health consumers, the foster home continues to survive as the oldest form of housing for persons with serious mental illness (Dorvil, Guttman, Ricard & Villeneuve, 1997; McCoin, 1983; 1985). Canadian foster homes¹ are analogous to the traditional adult foster home model in the US, defined as three or more individuals in a residential care facility, small group home, or family type setting under state regulation (Deci & Mattix, 1997). In Canada foster care has evolved from a “caretaking” to a “professional” model in which multi disciplinary teams play a key role. They supervise these homes and act as intermediaries between foster homes and the mental health system. Mental health workers are responsible for recruiting caregivers, as well as matching and placing consumers in these homes. A worker is also assigned to each resident, serving as case manager. According to Quebec Ministry of Health directives, an Individual Service Plan for each resident must be developed collaboratively between a resident’s worker and caregiver. The mandate of foster homes is to support persons with serious mental illness, and reintegrate them into the community. Increasingly, mental health consumers are expected to make the transition to independent living despite years of hospitalization, or unsuccessful previous attempts to live on their own. Very little updated information exists on life in foster homes, particularly from the perspective of those living there.

This article presents a set of findings around the competing needs of persons living in psychiatric foster homes. These findings are based on a larger study concerned with the nature of helping relationships between caregivers and residents in the Montreal foster home system. The findings emerged from two questions in the interview guide where residents were asked to describe the pros and cons of their living situations, and their needs in foster homes¹. The study emerged from the practice milieu. Multidisciplinary team members first identified the need to better understand the helping relationship in foster homes as an indication of how residents experience helping in this setting.

Historically, psychiatric foster homes have not been viewed in a positive light. This poor image dates back to the 1970s when Murphy et al (1972) completed one of the earliest studies on foster care in Canada. This study’s findings were highly critical of foster homes, which were viewed as places that merely provide room and board, are too structured and controlling, and do little to reintegrate people with serious mental illness in the community.

In Canada, as well as the US, policy makers are questioning the efficacy of the foster home model, and favor more autonomous types of housing (Kirby & Keon, 2006; MSSS, 2006; United States Government, 2003). According to numerous preference studies, most mental health consumers also prefer independent living. (Browne & Courtney, 2005; Carling & Allott, 2000; Keck, 1990; Ogilvie, 1997; Srebnick et al, 1995; Tanzman, 1993; Thomas, 1987). However, some studies (Carling & Allott, 2000; Gélinas et al, 2000; Palmer et al., 2000) reveal that consumers who already live, or have previously lived in independent housing, prefer this type of housing more than those who live in supervised housing, such as foster homes (Elliott et al., 1990; Rogers et al., 1991; Thomas, 1987).

A recent study (reference deleted blind review) reported a high level of satisfaction among 102 foster home residents with their living situation. Although the majority of respondents (59%) did not choose to live in a foster home – most often a family member or someone else chose for them – 89% preferred living in a foster home over other arrangements. The majority of respondents (80%) noted positive changes since their arrival in the home, and over two thirds wanted their foster home to be their permanent home. Although foster homes have been criticized in recent years, these findings suggest that this type of milieu responds to the needs of certain residents. However to date few studies have been conducted on the needs of people living in these homes, and thus the importance of exploring the perceptions of foster home residents.

Setting and Sample

The setting for the present study included Montreal adult foster homes for persons with serious mental illness supervised by two university-affiliated psychiatric hospitals. At the time of this study, there were 1402 individuals living in 267 foster homes. Sample selection was purposeful, and involved a two step process. First, a list of all foster homes (n=267) was compiled according to: 1) the number of residents living in the foster home (one to three residents; four to six residents; seven to nine residents) and 2) the caregiver’s years of experience as a caregiver (less than five years; five to nine years; ten to fourteen years; fifteen or more years). These two selection criteria were used based on consultations with staff, who felt that these were important issues to consider when selecting a diversified sample of foster homes. Following this twenty foster homes and their caregivers were selected for the first phase of the study in which caregivers were interviewed. In the second phase of the study a list of all residents living in these twenty pre selected homes was compiled. Residents with a primary diagnosis of intellectual disability, and those on public curatorship were excluded. The final sample of residents was selected purposefully to maximize variation in sex, age, length of stay in the home, and ability to discuss their experiences. Staff recommended three or four residents from each pre-selected home who met the study criteria, and made initial contact with them. However, the final selection of one to two residents per home was determined by members of the research team, who followed up by telephone with those residents who had expressed a willingness to participate.

Study Participants

Thirty-eight residents were contacted from the twenty designated foster homes. Thirty-three agreed to participate in the study, and five refused due to lack of interest. The participants were twenty men and thirteen women. Resident ages ranged from twenty-eight to seventy-two years, with a mean age of fifty-two. Twenty-one (21/33) were single; the rest were divorced/separated, or widowed. Residents’ predominant self-reported diagnoses were schizophrenia (14/33) and mood disorders (13/33).

Seventeen residents completed some high school, whereas eight had less than grade nine. Four residents had some university education, and two had attended technical schools. Among the 29/33 residents who had been employed at some point, twenty-three (23/33) had worked full time. At the time of the study, eight (8/33) were employed and one person was studying. The remainder were on social security.

Participants described three different pathways into foster care. The majority (20/33) came from hospital psychiatric units; eight (8/33) had been living in the community in some type of structured housing, and five (5/33) lived with family. At the time of the study, the average length of stay in their foster home was 6 years. Table 1 presents the demographic profile of the participants.

Table 1.

Socio-demographic characteristics - residents

	Length of stay in present foster home
Socio-demographic variables	0–3 years	4–6 years	7–9 years	10+ years
Number of residents	14 (42.4)*	6 (18.2)	6 (18.2)	7 (21.2)
Mean ages	51.7 (13.1)	51.0 (12.5)	50.0 (9.1)	55.0 (9.9)
Gender
Male	8 (24.2)	4 (12.1)	3 (9.1)	5 (15.2)
Female	6 (18.2)	2 (6.1)	3 (9.1)	2 (6.1)
Self-reported diagnosis**
Mood disorders	7 (21.2)	2 (6.1)	0 (0.0)	2 (6.1)
Schizophrenia	4 (12.1)	2 (6.1)	2 (6.1)	4 (12.1)
Bipolar disorder	1 (3.0)	0 (0.0)	1 (3.0)	0 (0.0)
Personality disorder	0 (3.0)	0 (0.0)	0 (3.0)	1 (3.0)
Does not know	1 (3.0)	1 (0.0)	3 (9.1)	1 (3.0)
NA	1 (3.0)	1 (3.0)	0 (0.0)	0 (0.0)
Previous foster home
Yes	9 (27.3)	5 (15.2)	4 (12.1)	5 (15.2)
No	5 (15.2)	1 (3.0)	2 (6.1)	2 (6.1)

^*Percentages are reported for all variables, except mean ages for which standard deviations were calculated.

^**One respondent in group 4 (10+ years) reported two diagnoses.

Procedure

Semi-structured interview guides were developed from consultations with members of multidisciplinary teams. The principal investigator and two research assistants conducted semi-structured interviews with residents between February and September, 2003. Interviews were 45 to 60 minutes in duration, were audio recorded and transcribed verbatim. After each interview, a short demographic questionnaire was administered. Interviewers took notes during the interviews to improve understanding or to generate new questions. Field notes were written after the interviews for later use in data analysis (Patton, 1990). The interview guide was pre-tested with two residents, and resulted in minor modifications.

Data Analysis

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, & Allan, 1993, 45). We chose this approach as most appropriate to explore the views of foster home residents concerning how foster homes respond to their needs.

Data analysis was inductive and ongoing throughout this study (Erlandson et al., 1993; Lincoln & Guba, 1985). No pre-set theoretical framework influenced data analysis. Thus, conceptualization of the phenomena under investigation was dependent on the findings that emerged from the data. Analysis involved several stages. First 7 interviews (transcriptions) were coded individually by three members of the research team. Inter-rater reliability was between 70–80% which meets acceptable standards for qualitative research (Boyatzis, 1998). Following this the remaining interviews were coded by one member of the research team. Initial codes were developed from the questionnaire and new codes were added as they emerged from the data. In all, there were nine iterations of the codes. These were then grouped into categories, ie resident perception of own needs/difficulties, and then into major themes, ie. need for human interaction, friendship.

Following this, analytical summaries were completed for fifty percent of the coded interviews at which point saturation was attained. These summaries, which provided a detailed reconstruction of each interview, were then compared and contrasted and written as a single summary. The codes for the remaining 50% of the interviews were merged into the single analytical summary. The ethics review boards of both hospitals approved the research. Participants gave written, informed consent, and retained a copy of the consent form. No identifying information is reported in the findings. Specific efforts were taken to ensure the trustworthiness of the study. Data analysis was a shared process involving constant feedback and discussion among members of the research team. Throughout the data analysis, many drafts of each set of findings were revised individually and then by team members. The principal investigator and one research assistant met weekly over a two-year period, from November 2004 to November 2006. The entire team, which included the principal investigator, a co-investigator, and two research assistants, read all drafts of the findings individually, and met in twelve work sessions between February and November, 2006. A detailed audit trail was kept over the course of the study. This included: raw data (interview guides/transcriptions); and data reduction and analysis materials (interview summaries, codebooks, and field/process notes.)

Results

People living in foster homes describe the tensions associated with foster home life: Two competing needs emerged: (1) the need to build a life around the foster home versus (2) the need to move beyond it. Figure 1 summarizes these findings :

Figure 1.

Competing Needs of Foster Home Residents

Building life around the foster home

For many residents, life revolves around the foster home. Twenty-seven out of the thirty-three residents (27/33) articulate their needs in relation to building their lives around the foster home. Four themes emerge: 1) human interaction and belonging; 2) friendship and mutual help; 3) good quality of life; and 4) support, stability and security.

Human interaction and belonging

Eleven residents (11/27) reported that the foster home provides many opportunities for human interaction. Residents emphasized that communication with others in the foster home is important:

… to be able to communicate, that’s it… It’s always that. That’s what’s important for me… to communicate sometimes I feel, I can’t communicate everything that I feel.. but it passes, because I like to talk a lot

They can be lonely, and find it « … exhilarating to just talk … to a person » in the home. Others who consider themselves more independent still appreciate a human touch on holidays or their birthday from their caregiver.

Some residents (7/27) stressed the importance of human interaction with their caregiver, one recounting how he was helped to break out of isolation after the death of his parents:

. .before I was like sleep walking… I was closed in on myself. Before that I didn’t talk…. It’s here that they were able to open me up…

Friendship and mutual help

The foster home often fills a void by providing opportunities for friendship. According to one resident: « a person can’t be cured, but they can be friends ». Residents referred to their housemates as “nice friends”, or claimed that “we’re all friends” in the home. Friendship provides both moral and mutual support:

Well, I needed a place to build up my morale…not a place to isolate myself… I’m like every other human, you need company, you need a friend.

One resident describes working together to serve breakfast, while another refers to “looking after one another”.

Residents (10/27) also spoke about sibling-like relationships that develop with other residents in the foster home. For one resident, a woman in his home is “sort of a sister”; another has discovered a brother:

… he’s sort of like a brother I never had, and I enjoy his company …I play chess with him. He’s beaten me almost every game, except one (laugh) where he was really tired, and I got him! (laugh) . . and he’s very, very nice”.

Friendships in foster homes cut across age differences. For one young resident, the older men in his home are role models. Another resident described how a friendship developed between himself and an eighty-seven year old resident whom he helped with daily tasks.

Friendship in foster homes has particular significance for residents with a history of addiction. The foster residence has helped two residents get on the right track: as one stated: “eliminate dope, and love your brother.’” Another claimed that the foster home helped him cut his former drug ties:

… my circle of friends, it was all those people that take drugs that I had as friends… so I got rid of them…I tore out the pages from my book, my address book, I threw it away… now I’m around other people who you can have a normal conversation with.

Residents point out that relationships in the homes are not always ideal. As one observed, she would not ordinarily choose the women in her home as friends; but they are “human life”, and she needs this. Another resident feels that she and her housemate have drifted apart over the years; yet they still do things together and support each other. Residents struggling to build their life around the foster home try to make things work. One describes how he manages a bad-tempered roommate:

… I just don’t talk to him much first of all. And when we do talk, when he gets into his temper … he growls … like grrrrrrrr!! …when he starts that, I just walk away.

A good quality of life

Residents (17/27) appreciate their foster homes for the quality of life provided there. Positive features include good food, clean clothes and a clean home, and amenities such as telephone and television. They also described idiosyncratic comfort needs, small pleasures and amusements that make foster residences « homey ». For one resident, having her own sheets was important. Another’s pleasure is freedom to roam the neighbourhood with money and dope in his pocket. Another resident loves her caregiver’s cats, insisting that happiness is made up of these small, everyday details. Private space and time alone, both provided in some foster homes, are other aspects of quality life. Two residents gloated over their large, private rooms, one calling it his “kingdom”.

Support, stability and security

The foster home provides many residents with support, stability and security -a refuge or protection from bad things or people. As one resident stated with regard to his home, it “gives you peace of mind … “Another describes himself as a “fifty-five year old foster child”; adding that, if it weren’t for the foster home, he would be, “not a hobo, but homeless”. Others agree they are happy to be off the streets. One woman credits the foster home with protecting her from substance abuse:

… I knew that by staying in the foster home, well I would be … like…protected… Well… it protects us a bit from bad things.

Residents stated that foster homes meet their need for everyday support with various concerns. Supervision of medications is especially crucial for controlling psychosis or depression. Residents (8/27) also observed that other medical problems intensify with age. One resident illustrated the interweave of physical, mental and social difficulties that create incentives for residents to rely on the foster home for support:

I have thyroid problems, I have diabetes problems; I have psychosis problems. I have diet … poor food emission; poor clothes in winter, hot in summer, nowhere to go.

Building Life Beyond the Foster Home

For eighteen (18/33) residents, communal living fuels the desire for more autonomy. They describe building life beyond the foster home in terms of three themes: 1) the foster home as a stepping stone; 2) drawbacks to communal living; and 3) need for personal autonomy and work.

The foster home as a stepping stone

In their efforts to move on, residents describe the foster home as a point of departure, a “stepping stone”, or “bridge” to the outside world. The foster home is a vehicle for adapting to society. One resident, feels that the foster home will help mitigate the stigma of being ill: Another resident, commenting on how the foster home gave him a “new vision and strength to continue”, likens the home to a “launching pad”

….if I would have stayed on the street, I wouldn’t have written very much, I wouldn’t have done very much. Sometimes the place where we live… it gives me strength… like a rocket that’s going to be launched in the sky … anyways… it’s the basis for launching.. that’s it.

Drawbacks to communal life

Residents described various drawbacks to living in foster homes. Eight residents (8/27) describe efforts to get away from the residence and its environment, the overall complaint being that « people are a hassle ». One resident drew attention to the main drawback: « don’t forget that we all have our illnesses ». Another referred to the challenge of communication among people who are psychotic : « I talk, I talk and … I’m talking to nobody ». Another resident gets so nervous from the negative environment that he stays in his room. Residents describe ongoing issues regarding cultural differences, negative behaviors and even gender :

… like they will slam the smoking room door, or … the bathroom door. They are … very noisy, the men. Whereas ladies are more quiet …. me and the other girls, we are more polite …

Residents must contend with each others’ jealousies: whereas two residents spoke about being careful with privileges, another puts himself above the problem: « They get jealous of each other, » he explains, « …. I never get jealous, because I’m on welfare -- haven’t worked in thirty years ». While one resident admitted that he changed foster homes due to interpersonal difficulties, another feels pushed out because of the difficulties created by living with low-functioning residents, and a third claims that caregivers always take a dislike to him, which has prompted several moves.

Need for personal autonomy and work

Residents oriented beyond the foster home express a desire to take charge of themselves and their lives. One claimed: « I’ve got on this way also on my own; and I can’t say that she (the caregiver) gave me everything that I know; … what would I be thinking about myself?” Other residents spoke in the same spirit, saying, for instance, « I took hold of myself. » or, “I am my own main professional worker”.

Some residents viewed the foster home as “just a place to occupy time”; they feel held back. Prevented from preparing his own meals, one resident complained that his only privilege was to “let himself be served”. Another resident, dissatisfied with the lack of freedom in her home, asks her caregiver for more tasks. A third wants to do his own outreach, to meet “new and interesting individuals, and do … things that … would actually be therapeutic in my rehabilitation …”. He voices frustration at his slow progress: “it’s sort of like a vicious cycle that … always lands against me, and I don’t really end up with anything”

Residents recognize that remunerated work is essential to moving on. They described common experience of persons with mental illness: their need for steady and substantial income in order to cover medications and become self-supporting. However, the mental illness undermines the stamina and stability required to maintain a job. A resident counting on employment in order to live independently complained that his permanent disability status may never be lifted. Residents also find sheltered workshops with their token remuneration a “waste of time,” and another “humiliation”. One resident refused his $5.00 a week out of pride, but felt forced to keep the job just to get out of the house. By contrast, another resident who landed a job in a corner store, described benefits of regular employment:

… to work with the public, and see people, … lock me up in a workshop there… I’m used working more than that, you know… I can make good money.

Visions of the future: Anxiety/fear versus Hope

The tension between staying in the foster home and moving on is best exemplified in residents’ outlooks on the future. Whereas residents desirous of building their future around the foster home experience anxiety when they look ahead, those oriented beyond the confines of the foster home have a sense of hope and momentum.

Fears about what will happen to them, and where will they go if the caregiver closes her home, loom large among residents attached to their foster homes. As one resident states:

… I think I live from day to day…. sometimes I think about the future.. what’s going to happen when let’s say.. that I retire… or where will I go?… that worries me.

Some have already experienced the upheaval of displacement to temporary quarters when their caregiver took sick. One aging resident describes the spectre of losing her only home:

Getting older and wondering what the future is going to be like … because … she’s not always going to be the caregiver; and she might suddenly up and leave. It’s our house; and where will we be, you know? And that’s what worries me a lot …

By contrast, the question « (w)hat will I be doing for the rest of my life? » spurred eight residents (8/27), who envisage themselves moving beyond the foster home, to formulate concrete goals and plans for the future. One resident stays focused despite the setback of her transfer to the foster home: “I know that next month they’re opening a new … apartment in the West and … that I’m going to be able to live there”. Another desires to “cope with himself, as well as function with the problems in today’s world”, adding that, if he could find a decently paid job, he could live independently. Another resident is saving money from his monthly allowance, and has enlisted his sister’s help to purchase household supplies in view of an eventual move. Another, still attracted to criminal activities, had found a friend with whom he hopes to live, and “do business”.

For one resident with an optimistic view of the future, each foster home experience brings him closer to recovery:

I kept noticing that … I ‘m getting better, and this… it will be the third foster home; I’m getting better and that … I was even in a, in very many ways lucky … to make me functional within society, you know …

Another resident maintains a kind of faith in a more positive future where she can somehow move beyond her illness:

… I’m always looking forward to the future; I’m always thinking that … you know, that there’s things to look forward to; that this isn’t just the end of the road…. I just have the faith, the hope, the courage to trust in the universe – like she (caregiver) says: ‘trust in the universe and things will work out’.

Residents who have hope for the future take comfort in the awareness that they are human like others, and that they have the same opportunity for self-improvement.

Discussion

Findings from this study shed light on the lived experience of people with serious mental illness in Montreal foster homes. As residents describe their life in these homes they articulate a complex and competing array of emotional and material needs : the need for security and support versus the need for greater personal autonomy, dilemmas associated with communal living, and the struggle to envisage a positive future. This study is especially interesting from two perspectives. First, these findings underline the importance of residents’ concerns over what type of housing will best meet their present and future needs. Second, the richness of resident accounts provides us with a more in depth understanding of the complexity of housing in a person’s life, particularly in the case of those persons living in foster homes.

As noted earlier, the foster home is frequently criticized as an outdated and ineffective housing model for mental health consumers (Carling, 1993; 1995; Trainor et al., 1993). However, much as residents demonstrate sensitivity to the foster home mandate, and the need move on and reintegrate into the community, not all foster home residents are prepared to embrace independent living. These findings are consistent with TAPS studies in Britain which support the view that people should not have to move onto other types of housing (Bigelow, 1998;) and that people develop important social networks, friendships and intimacy (Dayson, 1992; Dayson, Lee-Jones, Chahal, Leff, 1998). Similarly our findings reveal that there is a group of consumers who have oriented their lives around the foster home, and for compelling reasons. It must be recognized that, over time, foster home residents develop strong affective bonds among each other, and with their caregivers. Whether a move beyond the foster home occurs as a personal initiative, or at the inducement of professionals, efforts must be made to preserve the human relationships and patterns of mutual help that have developed in these homes. As well, adequate material and emotional supports, as well as opportunities for meaningful participation in community life, must be available, including remunerated work.

The distinctive characteristic of those residents who can envisage and look forward to life beyond the foster home is hope. Certain residents in this study believe that they can make it on their own, and are usually able to elaborate plans for the future. These residents fit the description of the consumer in recovery from mental illness, as they are taking back control of their lives. What they need are mental health professionals who are able to meet them halfway and encourage these aspirations.

Foster home residents are not alone in their experience of competing needs and tensions with regard to foster home life. The findings of this study help us better understand the dilemma often expressed by mental health professionals, who struggle between the need to protect their clients and their increasingly pressing mandate to reintegrate their clients into more autonomous housing.

These findings should be nuanced by certain limits of the study and its research methods. It should be noted that the resident sample is small, and biases of social desirability must be acknowledged. It should also be noted that the supply of other types of housing such as supported housing is somewhat limited in Montreal. Further research needs to be conducted comparing consumers living in foster homes with those living in more autonomous housing. As well future research should explore the experiences of those persons leaving foster homes for more autonomous living.

Conclusion

The dismantling of foster homes would be a heavy emotional loss for certain consumers who experience the foster home residence as their home. It is clear from this study that, before residents can move on, they must first perceive that there is a better life for them, and acceptance, outside the mental health system. They need to harness both their inner resources, and external resources, often the caregiver, for continued support in their efforts to move on. Finally, mental health staff should accompany residents closely, yet respect their pace, as these recovering individuals discover for themselves the viability of independent living.