‘Spot the difference’: Sweden International Case Study

How does secure care in Sweden differ from secure care practice in Scotland, and what can we learn from our Swedish colleagues? CYCJ’s Practice Development Advisor, Carole Dearie, reports back from a two-day international case study, discussing some valuable insights gained about secure care practice for vulnerable and high risk girls in Sweden, and how this knowledge may inform better practice in Scotland.

Following through on an invite to visit secure units in Sweden that provide secure care for vulnerable and high risk girls, myself and Claire Lightowler, Director CYCJ embarked on a two-day visit to one of the facilities in Stockholm. While there we also met with Dr Maria Andersson Vogel, researcher in the subject of vulnerable and high risk young girls. The visit was extremely informative and without doubt an excellent opportunity to build working partnerships that will hopefully lead to joint working in the future.

The purpose of the visit was twofold: one, to establish international links where practice could be discussed and shared; and two, to look at the differences and/or similarities in approaches that may be worthwhile considering here in Scotland.  Having both a practitioner and an academic focus allowed for a well balanced view of how one relates to the other.  As we set out to meet our Swedish colleagues, I anticipated we would find differences in key areas such as legislative and procedural frameworks, and this was indeed the case. But what about similarities? Would there be key themes shared in practice/attitudes and values that could not be separated by borders, language or cultures?

The first notable difference was not one that I had anticipated. The unit was set within a large forest area and had individual units spread out over the grounds. There were no high fences or walls and no security cameras scanning the grounds. You could be forgiven for questioning how this could be considered a secure unit. The answer to this was provided by the staff member who greeted us on arrival – the location of the units provides the security. With no villages or towns nearby (in fact, approximately four hours walking distance), absconding becomes a futile exercise for those young people considering ‘breaking free’. Interesting however, is that there is one unit that has high security fences and this is where all young girls are first placed on admission to the unit. With the risk of absconding being removed by the location it could be concluded that the high fences and security entrances are about containing the behaviours and risk presented by those young girls who are admitted into the unit.

The use of a location to provide security is not an alien concept here in Scotland. The first secure unit opened in 1960s in Scotland was built on ‘the Siberian Principle’; the idea that taking young people far away from civilisation will keep them secure and eliminate the risk they pose to communities. As Scotland developed its thinking about locking up young people, they conceded that secure units should be nearer communities in order to maintain links with families and social identities. This however, came at a cost as it meant that secure units had to be built so that fences and walls provide the security. I wondered how families kept contact when their kids were so far away, but was heartened to discover this is very much promoted, and with Sweden having an excellent travel network, the journey by public transport is, for many, not a difficult or arduous task. Furthermore, accommodation is made available for those family members who find the travelling to and from the unit too difficult.

Having been made to feel very welcome from the outset, it was clear that the Director of ‘Rebecka’ (one of the institutions that provide secure care for girls), Birgitta Dahlberg, and two of her staff, were as open to hearing about Scotland as we were to hearing about Sweden. This openness set the scene for a day packed with discussion and sharing. There were no concerns in relation to our ability to communicate effectively with our Swedish hosts as it is a well-established fact that Swedish people have an excellent command of the English language. However, some terminology used to describe the care given and the framework used to work with the young girls did present a challenge, as we sought to establish if in fact here in Scotland we did share the same practice, as the language inferred something different. Two obvious examples were ‘Investigation’ and ‘Treatment Plans’. This terminology inferred a medical and criminal justice approach. Teasing out some of this resulted in us being able to apply our terminology. Investigation = assessment and treatment plans = care plans. We wondered whether referring to treatment rather than care contributed to a different culture and attitude, implying as it does that change is possible and things can improve. Interestingly, Dr Andersson Vogel used the word  ‘care’ and not treatment, so again this was useful to know.

Grasping an understanding of the different legislation and different units in Sweden was challenging, but one thing stood out for me. Sweden has specific legislation for young people who offend and this takes into consideration the age of the young person. Unlike Scotland, where we have one Act (the Criminal Procedure(Scotland) Act 1995 that deals with people who offend regardless of age), Sweden has two key pieces of legislation that relate to secure care for young people. One piece of legislation deals with young people up to 21 years of age (LVU) and another deals with 15-17 year olds (LSU). LSU is criminal law whilst LVU is considered ‘welfare law’. Legislation that takes into consideration the age of the young person is a positive approach in youth justice as it keeps the focus on youth and perhaps allows for maturational development to be taken into account.  However, in terms of some of the policies around searching and call monitoring, I couldn’t help but feel that our practice here in Scotland was more focused on upholding the right to dignity and privacy. Secure units in Scotland are not permitted to ‘strip search’ and yet this is the practice in Sweden. Our practice, where albeit the young person is covered throughout the search, has been challenged as there is a school of thought that this procedure could re-traumatise those young girls who have been subject to abuse. It is well worth this line of thinking being pursued, regardless of the country it is happening in.

Some practices were for me very easy to say ‘like’ or ‘don’t like’; the two aforementioned being examples, but there is one that has me well and truly sitting on the fence!  What is it? Smoking! Now I know many reading this would quite easily put this in ‘like’ or ‘don’t like’ without any trouble but I believe it is at least worthy of consideration. All institutions for young people were non-smoking environments, however following an inspection by the Health Department (yes, you read that right) the decision was reversed, to allow smoking. For those of you experiencing cognitive dissonance right now in reconciling how Health can promote smoking in young people, then the answer lies in the rights of the young people. The staff are not permitted to supply or purchase cigarettes for the young people but if they have them brought during a visit, for example, then they can smoke them. There are still rules applied to monitoring amounts, etc, so it’s not free use or access that they have.

Staff describe how having a cigarette encourages engagement and attendance at school as young people know that they get a cigarette break there. Perhaps, however the most interesting bit for me was the use of cigarettes as a de-escalation technique. If the young girl was in crisis or potential crisis then a cigarette was used to effectively de-escalate the crisis. No one would want a young girl to be in crisis, but does the use of cigarettes detract from developing effective coping strategies and self-regulatory skills needed to manage the emotions of the crisis? And what about staff’s use of relationship and de-escalation techniques? Does having the option to give a cigarette disempower or detract them from using alternative methods during a crisis? These are questions worth considering. In Scotland, the secure units are all non-smoking and when young people are admitted they literally go from smoking to non-smoking when they arrive in the secure garage. For those young people who have to deal with the reality of losing their liberty, coupled with enforced nicotine withdrawal, can I’m sure be very overwhelming, but there is no recognition of the impact this may have on young people who have often smoked for many years. What needs to be in place is effective smoking cessation supports. I’m sure if you asked staff in secure units if they would like to be in the position of using a cigarette as a behaviour management technique then those who are honest would say ‘yes’ they would, as managing high levels of risk and challenging behaviour can be extremely demanding – however, I’m sure that they too would prefer that they work through the crisis and enable and empower the young person to develop the skills to manage their crisis. There are without doubt pros and cons to the smoking debate but one thing is clear and that is that rights and responsibilities must be balanced and that is never easy.

Another significant difference was the role that that Government played in the provision of secure care. In Sweden there is a National Board of institutional Care (SiS). This board oversees the running and governance of secure care with all policies and procedures coming from them.  Although this ensures consistency across all units, it does prevent any autonomy from being fostered by the Director and her team. The body responsible for secure care is the remit of Health and Social Services but it was acknowledged that in terms of partnership working between the disciplines there is room for improvement. An issue many may say is also pertinent to Scotland.

One glaring difference was Sweden’s ability to produce appropriate statistical information and data collation on key themes and issues around offending. I felt quite envious as I sat and listened to both practitioners and academics speak about and provide clear statistical information. This is something that would undoubtedly benefit Scotland as the lack of stats and data is a huge gap in our systems and knowledge. Relying on more anecdotal information as opposed to actual information does result in services and resources not always matching need.

There is so much more that could be written about this trip to Sweden but for now, suffice to say that this was a great experience and one that we should pursue in terms of developing an international working partnership. Let’s widen the net and share good practice.