Professionals’ account-making of institutional care for youths. Intertwined discretionary spaces and blurred collaborative practice

ABSTRACT

In this article, the account-making of social workers and institutional care staff on locked institutional care for youth is analysed, based on empirical material consisting of 10 interviews with 25 members of the two professions. The study departs from a Swedish context where locked institutional care for youth is mainly provided for individuals who are in compulsory care due to criminality, drug abuse, or other socially destructive behaviour. The analytical framework draws on account theory and Emerson’s concept of institutional care as a ‘last resort’. The results show that both social workers and staff use similar justifications and excuses, relating to organizational resources and rules and to assessments and decisions made by the other professional group; but also, that different layers of accounts overlap between professionals’ account-making stories and can change as care proceeds. The results are discussed in relation to the pooled discretion that is exercised when different professional groups are involved in care decisions, and the organizationally specialized care setting resulting in intertwined discretionary spaces and blurred practice, with consequences for the quality of care and challenges in holding professionals accountable.

KEYWORDS:

• Justifications
• professionals
• excuses
• institutional youth care
• collaboration

Introduction

When youth are placed in locked institutional care, two professional groups are responsible: social workers and institutional care staff. This article addresses the account-making of these professionals regarding locked institutional care for youth in Sweden, institutions with high restrictions often referred to as ‘total institutions’ (Goffman 1961). It is well known from research that there is a risk of negative outcomes when youth are placed in group care (e.g. Dishion, McCord, and Poulin 1999). In Sweden, young people at these institutions have severe but divergent social problems, often related to criminality and alcohol or substance abuse (Swedish National Board of Institutional Care 2023), and studies indicate that crime, problems at school, and poor mental health remain common issues after institutional care (Shannon 2011; Vogel 2012). Daily institutional life is described by the youths themselves in terms of boredom (Bengtsson 2012, Henriksen et al. 2023; Hill 2005; Wästerfors 2014) and as being in a vulnerable legal position (Enell, Mattsson, and Sallnäs 2023; Mattsson and Enell 2023). It has also been questioned if institutional care is appropriate for some vulnerable groups with specific needs, such as unaccompanied minors (Kaunitz and Jakobsson 2016; Padyab et al. 2020) and girls with mental health problems (Vogel 2012). The effectiveness of institutional care, and whether any treatment is provided, has been questioned. The use of resistant strategies in incarcerated institutions is also well known (e.g. Bosworth & Carrabine 2001). Hill (2005) has shown that both genuine alliances and sham alliances can develop between youth and staff, where the latter seems to be frequent due to the compulsory treatment conditions. Against this background, locked institutional care is often described as a last care option or ‘last resort’ (Emerson 1981).

With this in mind, it is interesting to analyse the account-making of social workers and institutional care staff, for decisions on institutional care as care proceeds, given their differing, yet, partly overlapping professional responsibilities and levels of discretion. In Sweden, a social worker applies for a place in institutional care and the social services have the overarching responsibility for the youth care and placement, while treatment assistants working as institutional care staff (henceforth ‘staff’) are responsible for the treatment provided at the institution and decisions concerning daily routines on a micro level (‘micro-decisions’). So, the questions we address in this article are: how do social workers and staff account for placements in locked institutional care, the content of care, and decisions made as care proceeds? How can professionals’ account-making be understood within the complex and collaborative practice of institutional youth care?

The Swedish context

Locked institutional care in Sweden is run by The National Board of Institutional Care (NBIC). Social workers use it for youth in compulsory care with behavioural problems such as criminality, drug abuse, or other antisocial behaviour. Many youths also have problematic home conditions and poor mental health (Vogel 2012). When locked institutional care is required, the social services contact the NBIC on behalf of the youth and apply for a place. It is the administrative court that decides on compulsory care, but the social services are overall responsible for the care and suggest and make decisions on placement (formally decided by the social committee in the municipality) and the social worker at the social services has a final say on specific care arrangements (degree of locked care, permission to leave the institution on special occasions etc). Staff at the institution are responsible for the treatment and to uphold the daily routines and order at the institution and have special legal authorities they may use (drug tests, body search, solitary confinement etc). There are 21 institutions in Sweden with approximately 700 places, and at the time of our study the NBIC was struggling to meet demand. This is however a recurring problem and since the NBIC is required to urgently provide a place in institutional care on request by the social services, necessary resources are also difficult to predict. The institutions are divided into different units, at the time for this study specialized in either investigation or treatment, and emergency units where youth can be placed for an initial period, generally for a maximum of eight weeks. Emergency units are primarily seen as a place for youths to establish basic routines (Ponnert, Johansson, and Svensson 2020). While social workers tend to use investigation units to attempt to take control of an uncontrolled care situation but also to pass on responsibility for the assessment (Enell and Denvall 2017), treatment units are expected to provide treatment conversations and different manual-based treatment programmes for reducing problems such as criminal behaviour and drug abuse (Ponnert, Johansson, and Svensson 2020). Since Sweden does not have any prisons specifically for youth, some institutions also have closed units for youth who have been sentenced to a fixed period in institutional care. However, compulsory care is not limited to a fixed time and may proceed until the youth reaches the age of 21. It is the social workers who assess and decide when the youth is ready to proceed to other units within institutional care or to other care arrangements.

Analytical framework

The field of study known as ‘the sociology of accounts’ looks at social actors’ verbal or written statements as attempts to explain and make sense of events. Scott and Lyman’s (1968) initial work on accounts theory was influenced by social interactionism (e.g. Goffman 1959). They define an account as ‘[…] a statement made by a social actor to explain unanticipated or untoward behaviour – whether that behaviour is his own or that of others […]’ (Scott and Lyman 1968, 46). They distinguish between two main types of accounts: justifications, where the actor accepts responsibility for the action but denies that the action was wrong or inappropriate; and excuses, where the actor admits that the action was wrong or inappropriate but denies responsibility. In research, account theory has mainly been used to explain the ways that individuals make sense of deviant or criminal behaviour and respond to ascriptions of blame, e.g. between couples (Buttny 1990), but also to analyse the reasoning of welfare professionals (e.g. Åkerström 2002; Dall 2020; Franzén and Aronsson 2018; Persson and Wästerfors 2009). Over time, the concept of accounts has been broadened from justifications and excuses to also include more ‘story-like’ explanations, and the process by which individuals develop an account (Orbuch 1997).

In our study, the idea of institutional care for youth as a last resort can be seen as part of the professional understanding influencing social workers’ and staffs’ accounts. Emerson (1981) distinguishes between ‘first-resort’, ‘last-resort’ and ‘dispreferred’ remedies in terms of different decision logics. First resorts are ideal solutions for what should or ought to be done, while dispreferred remedies are those that are usually not considered ideal but may be used or even preferred under certain circumstances. A last resort, however, is seen as the only option available in a particular situation, not as a choice between different available options (Emerson 1981). By viewing account-making as a process, we argue that a practice of commuting between different accounts for decisions can also be acknowledged. Here, Emerson (1981) also provides a helpful perspective. In his view, there are two ways to successfully account for a last-resort solution: to claim inappropriateness of normal remedies, due to the seriousness of the case, or to claim the failure/exhaustion of normal remedies.

In the discussion, we relate account-making by professionals to research on collaborative practices and discretion, with a specific focus on shared or ‘pooled discretion’ (Hood 2020) since this can be used to avoid or share blame. Pooled discretion may hence shed additional light on excuses within account-making when several professionals collaborate.

Related research and perspectives on collaborative practice

Social workers’ discretion is characterized by a formal authority based on the social services’ legal mandate and jurisdiction. The discretion of staff is somewhat different and can be understood as collective discretion, or group decision-making (Rutz and De Bont 2020). The ways in which social workers and staff reason about and understand their discretionary space (Molander 2016), meaning the boundaries for possible actions, is therefore of relevance when seeking to understand account-making within institutional care. In addition, there is a certain amount of overlap between the responsibilities and discretion of social workers and staff regarding care decisions, making interdependencies and collaboration between the two professional groups important. Evans (2010, 18) refers to a policy enacted by street-level bureaucrats as ‘a result of a complex, multi-layered and multi-actor process’. This has been further elaborated in discussions of the multiple actors involved in the review system of older people’s care home placements in the UK, blurring accountability for decisions in a fragmented care system (Scourfield 2015). Hood (2020) uses the term ‘pooled discretion’ to describe situations where the exercise of power is shared or pooled between multiple actors or organizations, which also functions as a way to spread and share the blame. Providing timely care in sync with youths’ needs is a challenge for social workers due to bureaucratic limitations and rules, missing relationships, and limited knowledge of the youth’s present situation (Andersen and Torbenfeldt Bengtsson 2019). Institutional care itself is also connected to negative stories due to the questioned outcome of care. Retelling and holding on to positive stories about social work and stressing the importance of their professional role in society as a ‘child saviour’ can also be seen as a way for social workers to relate to the negative stories with which the profession is often connected (Cook 2020).

Brunsson (2017) discusses the complexity of decision-making processes and argues that these processes are social phenomena which are not always guided by rationality. Rather than understanding decisions merely in terms of choice, it is important to see decisions ‘as an institution – as a well-known pattern of action with a ready-made account and with rules that are taken for granted’ (p. 1 ch. 1). Forkby and Höjer (2011) show how the decision-making process on placing youth in residential care in Sweden is influenced by a ‘collective memory’, where stories and experiences of good and bad care units are shared amongst social workers, and where assessments are discussed with colleagues and managers. They also show how residential care units in general, and not only locked institutions, are seen as a last resort, since they might be questioned in relation to research on outcome, costs, and a family-oriented perspective. A lack of available places in residential care was also highlighted by social workers as a problem, and a need to accept whatever place they could get (Forkby and Höjer 2011).

The specialization of institutional care into different units is also of interest in this article, since institutional care is organizationally framed as youth entering different units in a linear process following a rational ideal (Brunsson 2017). In addition, many social services in Sweden are organizationally specialized and differentiated into various units, which risks providing fragmented care that requires more coordination and collaboration in practice (Grell, Blom, and Ahmadi 2020, 2022) and calls for integration Axelsson and Bihari Axelsson (2006); Lawrence and Lorch (1967). The institutions, and the social services, are thus organized in ways that increase what Hood (2020) refers to as pooled discretion between several professionals within their respective organization. Dall (2020) has discussed responsibility in inter-professional rehabilitation teams in Denmark. She found that the professionals offered various accounts to manage inter-professional tensions and challenges, where legislation could be used as an excuse and deter responsibility, but also that inter-professional collaboration could be justified as beneficial, as could oppose, and instead emphasize the responsibility of the individual (Dall 2020). Research from the perspective of institutional staff, and collaboration with social services, is however scarce. Basic (2019) has analysed different professional actors’ narratives on successful collaboration within this context. He describes how inter-organizational collaboration identities and professional’s work identities interact and describes the construction of successful collaboration identities as ‘an ongoing, narrative process’ (Basic 2019, 246). Staff describes their work in terms of both care and risk management (Henriksen et al. 2023). Staff also need to find a balance between upholding institutional rules and being flexible towards individual needs, in a space where ‘micro-decisions’ are shared amongst staff (Svensson and Ponnert 2022) and staff may approach rules differently (Hill 2005; Kallenberg 2016). The legal boundaries for some restrictive measures are somewhat unclear, resulting in more or less restrictive approaches by staff concerning physical constraint (Mattsson and Enell 2023). Research also shows that staff themselves might feel powerless despite the authority they legally have within locked institutional care (cf. Bengtsson 2012; Kallenberg 2016).

Method

The empirical material derives from a qualitative research project on locked institutional care for youth in Sweden based on web questionnaires and interviews with staff and social workers, interviews with youths and field visits. The project had a focus on emergency units, and was presented in an overarching report (Ponnert, Johansson, and Svensson 2020). In this article, we further analyse the voices of social workers and staff, based on 10 interviews with 25 respondents.

Two group interviews and two individual interviews were conducted with a total of nine social workers (three men and six women) from four municipalities. They had varying experience in child protection, from five-and-a-half to 30 years. Many worked in specialized units within the social services, some with responsibility for youth in out-of-home care only, meaning that other social workers had been responsible for the initial care decision. A semi-structured interview guide was used based on themes related to the target group and purpose of emergency units, and questions related to collaboration and competence. Six group interviews (two to three participants/interview) were conducted with a total of 16 staff (nine men and seven women) at emergency units (four group interviews) and treatment units (two group interviews) at two institutions (A and B). The staff had between one-and-a-half and 10 years of work experience in institutional care, and many had experience from different care units. All, except from one, had education related to the work, mainly in social care, some had shorter academic studies, but none of the staff interviewees held a higher academic degree as opposed to the social workers. The group interviews with staff can be described as formal (semi-structured) field interviews (Frey and Fontana 1991) conducted at youth institutions. A semi-structured interview guide was used based on different themes and statements the staff should reflect on concerning perceived differences between emergency units and treatment units. All interviews took place during 2016– 2017.

The interviews have been transcribed verbatim and analysed with a focus on account-making. First, we identify examples of account-making that are characterized by justifications for decisions to place youth in institutional care (and especially at emergency units). Then, we explore how justifications and excuses are shaped in relation to the circumstances surrounding the two professional groups and the specific institutional care setting, and how they value each other’s competencies and assessments. Finally, we discuss how the account-making process is characterized by an interplay between justifications and excuses, and how the perceived boundaries for discretion affect decisions. Where quotes from interviews are provided, social worker is abbreviated as SW and staff are referred to as TA (treatment assistant). All professionals have provided informed consent and the project has been approved by the Regional Ethical Board in Lund in Sweden (dnr. 2015–98).

Findings

The results are presented under two main themes related to the care process: accounting for (the decision to use) institutional care and justifications and excuses concerning the provided care at these institutions.

Accounting for institutional care

Both social workers and staff justify institutional care using claims of inappropriateness of normal remedies and failure/exhaustion of normal remedies, in line with Emerson’s findings (Emerson 1981). The decision to place youth in institutional care is described by one social worker as being motivated by ‘a breakdown of previous open interventions that have not worked’ (Interview 1). The social workers want to avoid placement in general and institutional care in particular, and only use it when other interventions have failed. In addition, both social workers and staff stress the fact that other responsible authorities often fail, especially child and adolescent psychiatry services regarding youth (mainly girls) with mental health issues such as self-harm or suicidal behaviour. In these cases, institutional care is excused as the only care option left – since the youth are not taken into psychiatric care – yet it is also acknowledged as inappropriate.

SW 3: One thing I have been thinking about, many girls with mental illness, self-harm behaviour, suicidal and stuff, and we see that child and adolescent psychiatry doesn’t take responsibility. (Interview 3)

Similarly, staff said:

TA 5: What would happen to these girls then, who have been through so much? Nobody wants them. / … /Who will take care of them? Not the psychiatric clinic. (Emergency unit A2)

Institutional care and emergency units are thus framed in the interviews as life-saving interventions, stressing the importance of their respective professional role and responsibility and institutional care as a solution (c.f. Cook 2020). In line with Emerson (1981), the interviewees’ justifications of institutional care can be understood as commuting between, or as a mixture of, a ‘last-resort’ remedy (the only option left) and a ‘dispreferred remedy’ that has become necessary in order to save the youth. The inappropriateness and failure of earlier interventions can be understood as an overarching justification for institutional care, although elsewhere in the interview material, other accounts are found to support both the placement decision and subsequent decisions made during care.

Time for respite- emergency units

One sub-account used to justify institutional care was time for respite, to provide time for reflection for the professionals, knowing that the youth is in a safe place. This was mostly in the form of justification of the use of emergency units, which do not provide either investigation or treatment.

SW 8: If we choose emergency placement, it must be now, here and now. Locked care is required, [for] youth who do not fit in anywhere else. That is when we use state institutional care. /---/ But often an emergency unit also provides time, partly to protect them, and an opportunity for us to think further. What should we think about in the next step? Are we still thinking about NBIC? Is that protection required? Or can we send them home, or to foster homes, or to [open] residential care units? So, there is some time for reflection for both us and the youth together with their family. So, I think there are two purposes, both to protect [the youth] and to think things through. (Interview 4)

Staff similarly accounted for the specific need for emergency units as a way for social workers to get time for respite, but also for them as professionals (and the institution) to have time to get to know the youth.

Interviewer: Why does a youth need an emergency unit, why can’t he or she immediately be placed at a treatment unit? If it was locked.

TA 4: It is because we don’t know the girl. But it can happen that a girl arrives that has been here before. And we do know her. Then it is about safeguarding. Is she carrying any drugs? What has she taken? What has she experienced? Does she need to see a doctor? (Emergency unit A2)

However, time for respite could also be for the youth, to give them time to think and adjust to a routine. Staff also claimed that emergency units in particular could be used as a ‘cooling-off place’, free from some of the demands at treatment units.

TA 3: Sometimes they come to us from the unlocked treatment unit or other places, to calm down if things have gone wrong. Spend time at our emergency unit for a couple of weeks, and then go back. It is a bit of a warning to them, to think and calm down. (Emergency unit A1)

Placement at emergency units in particular is thus accounted for not only as a last resort or dispreferred remedy, but also as an opportunity to get time for respite – often for both the professionals and the youth.

Justifications and excuses concerning the provided care

Social workers’ and staff’s accounts of the actual care given at the institution varied depending on how the care was perceived. It was sometimes justified and at other times excused, which illustrates how the account-making of these groups of professionals is characterized by an ambivalence and commuting between justifications and excuses.

“Good-enough” care at emergency units- moderate expectations

Given the recognized challenges in institutional care, social workers stressed it as a last resort. However, at times they also justified institutional care by suggesting that the youth was better off at an institution, given the severity of their circumstances. The social workers’ expectations of emergency units were not to give high-quality treatment, but rather to provide basic care and protection within a locked facility.

SW 8: Protection and motivation. Then I am satisfied. If they do it with dignity and interest, then we are satisfied. We don’t have higher demands [than that] on emergency units. It is youth who come straight from the street, [and] they end up with [other] youths in the same situation. But with a dignified approach and protection and motivation, we are very satisfied. (Interview 4)

In the quote above, the social worker first justifies the care provided at emergency units as ‘good-enough care’; then acknowledges that institutional care for youth with similar problems is in general ‘bad’ (excuse); and then again justifies the provision of protection and a professional approach as being good enough in the given situation. This could be interpreted as choosing a last resort placement might also result in lower expectations on the content and quality of care from a social worker perspective, although they stress the need for a professional approach amongst staff.

Justifications related to good-enough care at emergency units were however expressed by staff as well:

TA 4: They have been fed at specific times and reasonably nice adults have looked after them. I think that goes a long way. (Emergency unit A2)

Staff also stressed that many youths thrive at the emergency units.

TA 3. They thrive with us. Usually. But they still want to move on, so to speak. Until they move, then they want to stay. But at our place, it is like a roundabout, they just walk around and wait until they are sent somewhere else. So with us, they really get nowhere. Or they do, but they get sent to treatment residential care, they see no end to the chain. Well, they will it if they get a place to come to. (Emergency unit A1)

The last quote also demonstrates an ambivalent account-making, stressing how youth thrive at the emergency unit, but want to move on, yet stay; how emergency units can be seen as negative or challenging (since the youth are not really moving forward), and yet contribute to youth eventually moving on to somewhere else in the system.

Wrong care at the wrong time

Social workers and staff felt that the possibilities to provide the right care and unit for youths at the right time were impaired by a lack of organizational resources, resulting in long wait times. In addition, it was felt that organizational rules and inadequate assessments and competencies on the part of the other professional group could also negatively affect the content of care.

Wait times as an obstacle

In line with previous studies, the bureaucratic limitations for providing timely care were expressed by social workers (Andersen and Torbenfeldt Bengtsson 2019; Forkby and Höjer 2011). In the interviews we found expressions of social workers’ concerns about difficulties meeting the needs of individual youths due to long wait times throughout the entire institutional care system, not only for places at emergency units but also in investigation and treatment units. Wait times as problematic were also expressed by social workers in web questionnaires conducted within the project (Ponnert, Johansson, and Svensson 2020). Since the social services according to law have the ultimate responsibility to provide necessary support and care, this was seen as a professional and ethical dilemma, since a compulsory care decision requires somewhere to place the youth.

SW 4: The problem is if we choose compulsory care, we need to have somewhere to place them, and then there aren’t any places available. That becomes very difficult.

SW 7: The question then is who is responsible if the youths kill themselves, I wonder.

SW 6: Or kills somebody else.

SW 7: Yes, or if it happens. Yes, whatever happens.

SW 5: And then, we need to sign a decision that we place them at state institutional care, but that there is no room.

SW 7: Yes, that is desirable. But I still think we will be the one who is to blame.

SW 5: Legally it also becomes problematic, because we need to do everything within our power. And some youth, you cannot tell them that they are to be taken into care, because there is a risk that they will hurt themselves or others or run away. So, you need a place [at an institution] to be able to inform them about the compulsory care decision. (Interview 3)

Social workers could thus find themselves in situations where they are legally accountable for the consequences of a lack of places within institutional care. The social workers also expressed a need to ‘take the place they are given’ due to the long wait times, especially for treatment units, and a lack of opportunity to choose the appropriate unit according to the individual’s needs (c.f. Forkby and Höjer 2011).

SW 2: Most placements are at emergency units, because there is rarely a place available at a treatment unit. There is a long queue. (Interview 2)

In this context, the social workers account for treatment units as ‘first resorts’ within institutional care and emergency units as dispreferred remedies, although places at the former were often not available. The social workers highlight matching the individual to the right unit as crucial for the youths’ motivation, but as impossible to achieve, and therefore excused, due to organizational constraints within the institutional care system (Ponnert, Johansson, and Svensson 2020).

The social workers had higher expectations of treatment units compared to emergency units, to provide more specialized care adapted to the needs of the individual. For staff, the lack of places seemed to result in a feeling of having limited discretion and scope for professional action at treatment units compared to staff at emergency units. Staff at treatment units had education and training in treatment programmes intended for a specific target group. High pressures on institutional care had however resulted in treatment units receiving youths with all kinds of problems that were not necessarily catered for, leading to dissatisfaction amongst staff with the care they could provide.

TA 14: The trend seems to be that the youth are more difficult. We get less to say and less opportunities to do what we are good at. We are not listened to, instead it is like ‘you have to take this, you have a place available and that is how it is’. (Treatment unit B3)

The quote illustrates a feeling amongst staff as being powerless (c.f. Bengtsson 2012; Kallenberg 2016).

Questioned organisational rules and blaming the other professional group´s competencies

The account-making was sometimes characterized by excuses related to organizational rules and the other professional group´s assessments or competencies, often with blame directed at the other professional group. In connection with this, the professional’s own discretion was often perceived as limited, illustrating how the two professional groups occupy given discretionary spaces that are somewhat overlapping, thus making them interdependent and blurred in practice.

As an example, some social workers perceived emergency units as a requirement from the institutions, or even formally by NBIC, before placement at a treatment unit was possible, implying a shared responsibility between the institution and the social services for the choice of care unit, whereas this, in fact, is not a demand or decision that is legally possible for institutions to make. However, this was also discussed amongst the respondents since they had different experiences on this matter.

SW 4: At state institutional care they [the youth] have to be at an emergency unit first, they cannot go anywhere else before that. So even if they are investigated or have treatment, they are placed at an emergency unit first, because they [staff] want to control everything. So, everybody who enters state institutional care ends up in emergency units.

SW 5: Yes, that is probably how it has become, since there are no available treatment sites. Previously, we could get a kid straight to a treatment unit, but there are no places [now]. So, they have to enter an emergency unit to be able to get to treatment. /---/

SW 5: It becomes difficult when NBIC says different things to different people. It becomes a bit problematic.

SW 6: So now we are confused.

SW 3: Me too.

SW 4: Yes, really. (Interview 3)

This could be interpreted as an ambiguity in relation to the discretionary space and who is actually responsible for the choice of unit, NBIC or the social services.

In general, youth spend the first part of their time in the institution under high restrictions in a locked emergency unit, and it is up to the social worker to decide when the youth is allowed to go outdoors. According to law, youth should not be in locked care for more than two months, although this can be extended under certain circumstances. This can be problematic for youths and staff at emergency units, since they have few activities to offer besides schooling. Staff also talked about an organizational change that had taken place where emergency units were no longer allowed to provide education at the unit. Instead, the institution had a separate school building, which required that youths were allowed to leave the locked unit to attend school. In one interview, staff discussed the problems that could arise when they found themselves restricted by these new rules as well as by social workers’ decisions.

TA 9: It is a bit tragic. Previously we always had 14 days [in locked care], it was us at the emergency unit who decided. Partly, for the boy to get settled and for us to get to know him before he was let outside the unit. Then we have a dialogue with the social services. ‘Is it acceptable that we let him go outside after 14 days?’ Some thought this was OK, some didn’t, and then the youth had to stay inside. So that dialogue was there. So a lot of the youths looked forward to getting out and doing things. / … / But now, for those who can’t go out, there will be problems. It is still early days, but there will be youths who are not allowed to go out for eight weeks.

Interviewer: And it is the social services who decide?

TA 9: It is the social services who decide, and then it is really difficult.

Interviewer: Yes.

TA 9: How can you motivate such a boy to anything at all? (Emergency unit B2)

Staff thus justify the need for locked care but then excuse the content of care with reference to social workers’ decisions and organizational rules outside their control, which may result in a poor situation for youths at emergency units. As treatment programmes were not available at emergency units, it was a challenge to provide youths with meaningful activities indoors. The only tools available were motivational interview (MI) conversations and ADAD interviews (Adolescent Drug Abuse Diagnosis), and ‘this is done early on with a youth who is supposed to be indoors eight weeks’ (TA at Emergency unit B2). Some staff also said that possibilities to take the youths outdoors had diminished over time, which is excused by reference to inadequate resources and stricter rules related to risk assessments when youth leave the institution together with staff.

TA 7: It is a question of having the staff. In general, there need to be enough staff at the unit, because six youths aren’t allowed to go out while two others are allowed. (Emergency unit B1)

Social workers, in general, justify and take responsibility for the decision to place the youths in institutional care, but excuse the care given by referring to varied competence of staff and varied quality of care provided at different institutions, and their own limited discretion to influence the choice of institution and care unit. The social workers discuss how they cannot affect the choice of unit or the time that youths spend at different units. The quote below illustrates how account-making is shaped and characterized by a constant commuting between these different layers and types of accounts.

SW 9: They [staff] try, but there are, I mean, in and out with people who are feeling really bad. …

SW 8: And the varying skills of the staff. … So, some places are better than others … They get time to sober up, become drug-free, and think in new directions, but a lot of time disappears for the youths at an emergency unit if they don’t know where to go next.

SW 9: Yes, we have no opportunity to influence their placement.

SW 8: There is a shortage of places and varying quality of what we get. That’s how it is. … This is where our most difficult job really begins, when they are emergency placed in care. That’s when we really start working hard, on the next step. But then it is also required that the youth institution is on its toes.

SW 9: But that is also where the lack of places at the treatment and investigation units in state institutional care comes in. Whatever we decide, we do not control the date [a place is provided at a specific unit]. So, then it can be a long time [that they spend] at the emergency unit.

SW 8: But I think it goes well based on the situation as it is. It’s a bad thing, so it’s not a fun situation. So, I still think we work well with both clients and parents and networks that call and, yes, we try to be open as well. (Interview 4)

The tendency to commute between justifying and excusing the care can be seen here, as well as the tendency to provide accounts in the form of excuses that put blame on staff and lack of resources. Similar issues were raised in staff interviews, but as illustrated below, youths spending too long in institutional care could also be blamed on social workers’ assessments.

TA 15: (…) We had a boy who lived here for two years … I don’t know how many times we communicated [to the social worker] that he shouldn’t be here, it only gets worse. (Treatment unit B3)

Blaming the system or the other professional group for the provision of wrong care at the wrong time can be seen as an excuse Scott and Lyman (1968) refer to as scapegoating. Blaming is also possible due to the pooled discretion and responsibility between the professionals’ respective organizations. Some social workers also pointed to lack of experience amongst other social workers as problematic. Highly specialized organizations, where several professionals are involved in decisions regarding care, makes it possible to blame professionals both within and beyond the own organizations’ boundaries.

Last resort turns into first resort as care proceeds

Despite the overall story of locked institutional care as a last resort, the account-making could take a different direction once the youth was already in locked care. It seemed that once such a decision was taken, social workers could describe it as important not to end institutional care too abruptly.

SW 4: To move from NBIC [locked institutional care] to home is often way too big a step. And to move from NBIC to [open] residential care units might also be too big a step, but there is not much else. /---/ If you fail within NBIC it is not such a long way to fall, because it is within NBIC. But if you are placed at a residential care unit and fail and have to move back to NBIC, then it becomes quite a big failure. (Interview 3).

The need to avoid failure in open residential care could thus function as a justification for prolonged institutional care. This account is enhanced by the existence of different institutional units that are specialized in different tasks, which makes it possible to transfer youths from emergency units to treatment units and back again, without leaving the locked care setting.

Discussion

Social workers and staff were found to justify decisions to place youth in locked institutional care in line with Emerson’s findings: claims of inappropriateness of normal remedies, and failure/exhaustion of normal remedies. They also justify care at emergency units specifically, by claiming ‘time for respite’ for social workers, staff, and the youths themselves, and the provision of ‘good-enough care’. Both social workers and staff produce a story-like account where institutional care is framed as a life-saving intervention, and sometimes as result of the failure of child and adolescent psychiatry to take appropriate responsibility. At the same time, the two professional groups could excuse the content of care by referring to poor assessments or decisions made by the other professional group, or by referring to organizational rules and a lack of resources beyond their control. The interviews display evidence of justifications in the form of stories where one’s own professional group are presented as ‘heroes’ (cf. Cook 2020), and excuses where other actors are blamed or presented as ‘scapegoats’ (cf. Brunsson 2017; Scott and Lyman 1968). Accounts relating to rules and routines, and a lack of resources, have been found in other institutional settings as well (Dall 2020; Persson and Wästerfors 2009). Specific for our analysis, is the interdependence between the two professional groups in the complex care context and collaborative practice of institutional care for youth. Previous studies of institutional youth care have also shown how narratives of collaboration are intertwined with professional identity (Basic 2019), that staff might feel powerless despite the authority they possess in this context (c.f. Bengtsson 2012; Kallenberg 2016), and how social workers’ choice of residential care unit is restricted due to a lack of available places (Forkby and Höjer 2011).

In our study, social workers’ account-making could shift from framing institutional care in general as a last-resort, to framing treatment units as a first-resort response once the youth was taken into care. The existence of different specialized units within institutions seemed to enhance this account and function as an argument for prolonging institutional care, along with the need to avoid a breakdown in open care. The consequences for youths are problematic, since their total time in locked institutional care may be longer than necessary (Ponnert, Johansson, and Svensson 2020). The accounts presented in this analysis can be understood in light of the shared or overlapping responsibility and discretion that exists among different organizations (social services and institutional care units) and professionals (social workers and staff) in relation to youths in institutional care. Shared power between multiple actors and organizations may also function as a way to spread responsibility (Hood 2020; cf.; Enell and Denvall 2017). However, it may also result in problems discerning who is responsible for a decision, thereby blurring accountability (Brunsson 2017; Scourfield 2015). Brunsson (2017) claims that when a major decision is split up into a series of minor ones, ‘the amount of responsibility for each decision is reduced’ (Brunsson 2017, 9, ch. 2).

This study shows how social workers and staff are required to navigate and account for institutional care within a pooled discretion, where responsibility is shared or overlapping, but where both professional groups express feelings of being powerless and hence not (fully) accountable for the outcome of care. The pooled discretion shapes account-making of institutional care in a way that leads professionals to commute between justifying placement in institutional care, excusing the content of care, and in other ways justifying the content of care – all mixed, where professionals might refer to different organizations, actors, and circumstances out of their control and consequently avoid being (fully) personally or morally accountable for the actual care given. This also shows how social workers’ and treatment assistants’ discretionary spaces are intertwined, which is used by professionals to account for ‘bad’ decisions or outcomes of care. The discretionary space formally ‘given’ to each professional group, gets blurred in practice due to their interdependence. The results are based on a limited number of interviews in a Swedish context and more studies are needed to further explore the account-making and consequences of pooled discretion within institutional care in different national contexts and settings. By focusing on the two professional groups, social workers and institutional care staff, the intertwined discretionary space in this collaborative practice is illuminated, enhancing the knowledge of how institutional youth care can be accounted for despite its known challenges.

Conclusion and implications

Decisions on locked institutional care for youth are accounted for in a complex context and collaborative practice, where the social services formally have the main responsibility. Even if one social worker is responsible for the assessment of the youth’s needs, the responsible social worker can also change during the process due to organizational specialization and a high turnover amongst social workers (Ponnert, Johansson, and Svensson 2020). The micro-decisions taken by staff can be seen as a result of their shared collective discretion, since they work in teams and at different hours at the institution (cf. Rutz and De Bont 2020). The discretion of the two professional groups is pooled both vertically (hierarchically between the social services and the institution) and horizontally (between different units at the organizational level, and between different individual staff members and social workers), which illustrates the interdependence between the various professionals involved. In such a complex context, the collaborative processes are often challenging (Axelsson and Bihari Axelsson 2006; Huxham 1996; Johansson 2011) and call for integration, clarification of responsibilities, and developing of trust and collaboration between the organizations and professionals involved.

The intertwined discretionary spaces between social workers and staff in institutional care are problematic for the youths, whose daily lives in institutional care depend on the decisions and exercise of power by professionals. Institutional care has been problematized from a child rights perspective due to youths’ dependency on how staff interpret and use legal rules (Mattsson and Enell 2023). Intertwined discretionary spaces also make it hard to distinguish who is accountable for decisions and for the care provided and might diffuse or change the balance of power between the organizations and professions involved in unprecedented ways (cf. Johansson 2011), as well as hinder the youths’ influence and participation in decision-making processes affecting them. The effect of organizational circumstances on the professionals’ account-making and decisions regarding institutional care for youth is also important. In our analysis, this was seen to reduce the possibilities to provide the right care at the right time. Moreover, the ‘time for respite’ account is important to reflect on in terms of how it corresponds to the legal basis of locked institutional care for youth. By providing knowledge about justifications and excuses provided by different professionals as care proceeds, the vulnerabilities in the system are highlighted and may be further discussed and researched from a child rights perspective and a professional perspective.

Acknowledgement

The study consisted of different substudies. Professor Kerstin Svensson participated in conducting the group interviews with institutional care staff and has also participated in analysing these from a different perspective in previous publications. We would like to thank all social workers and institutional care staff who contributed to the interviews.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the National board of institutional care [Dnr 2.6.1-647-2014].