Contingencies of resettlements (Macedonia) - methods and reception

Little is known of methods used in the first resettlement action (Kriva Palanka). In the first wave of resettlements for Demir Kapija, the methods of assessment and training of the residents that would eventually leave were extensively used. The other part of work was to create day centres, recruit the fosterers and instruct them. In the second wave, the process was planned as by the book and there was more accent on getting the institution as whole involved, more assessment was done on the institution and its resources (staff, amenities). The future carers had a brief but intensive and up to date training. However, it seems something went wrong in the relationships and not everything went the way it was planned and created a schism between the institution, its staff and the external actors who were instrumental in the resettlement process. It looks like the crew responsible for the project got focus on the outcomes and did not let the process stop the resettlements.

Personal plans were used in that period, but not as a basic instrument of resettlement (as a resettlement plan), since the residents were moving collectively into group homes. They were used more to foster users’ perspective, to get the idea of likes and dislikes of the residents exiting the institution. Although the staff of new services has this knowledge, they do not use it as the main tool of the service delivery. We can assume that this is partly the case also because there is not a perspective of move from the group homes on.

That something was lost in terms of the methods during the process is also the impression received in Demir Kapija. Through the years, they have been exposed through various projects, to many methods and some have been developed on their own (cf.: teamwork in the annexe). However, the context of their work and the depressive attitude of resisting change has made staff less motivated to use those trainings and new methods of working. Nevertheless, the methods of ‘intensive interaction’ and personal planning introduced to Demir Kapija staff in recent months have been seen as important contribution to their work, tools of value in the future resettlements and were welcome. These two ways of working seem to be of great importance, since they provide tools of understanding and breaching the gap between the residents who are not able to express themselves in conventional manner and give the staff the vision of what they want, like and wish in their lives. Coupled with training in teamwork, organising new community services, risk taking and assessment methods and change management they would form a necessary pack that the staff of transforming institution should possess.

The reception of the community of the resettled residents was mainly good and welcoming. The interviews with various community members confirm this. They know that conditions in the institutions are bad, but often do not see the alternative since (as noted above) they believe that institutions are as a place where people are treated, cared for – “they have a doctor there (which in fact they have not) and can be given medicaments; they are better off in there than staying home”. Some more informed members of community have heard of the deinstitutionalisation or when they hear what it is about, they approve it and see its merit. A special educator in one of the day centres supports the process, but warns about the conditions that need to be fulfilled, i.e. that it is done completely and that all the residents have a chance for better life.

It looks like ex-residents were as a rule well received and that there was not much of the resistance against the new comers. The NIMBY (not in my back yard) effect was recorded, paradoxically, only in an attempt of the infants’ home to establish a group home for the children that out-grew the requirements of the institution (surpassed the age of three). The group home was planned to be in a ‘well-to-do’ suburban community and parents in the area petitioned against it – not wanting that their children would be in the same kindergarten with Gipsies. The discrimination and racism presented was, in this case, not against the disability but against Roma (children).

The protagonist of the second wave resettlement emphasise that it was more difficult for the users to be accepted by the neighbours and to access other services in Skopje rather than in Volkovo, which is a small community (settlement or village) close to Skopje, the people are friendlier and are accepting the users much easily. Here, the development of the users is much easier because after the day activities and according to personal wishes they go to the city for leisure and entertainment, visiting cultural and sports events etc. In Negotino, which is also a smaller local community, people are more tolerant and willing to provide help; the users have more opportunities to use local services and resources.  This opinion is partly true, but partly can be seen as a rationalisation of the fact that they had to move out of Skopje for economic reasons and we should be careful not to have over idyllic expectations regarding future resettlements. There are good and bad sides of different environments. While there is more of a community spirit and less anomia in smaller towns and communities, the city folks are more tolerant and there are more opportunities (e.g. for service support) in the cities.

The strong value and the norm of hospitality, generousness and compassion in Macedonian culture definitely helps the reception of people who return from the institutions. The part of the culture that is an obstacle to inclusion is the feeling of uneasiness and shame of such people to belong to one’s family. 

Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008–2018, which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector. For this blog, Vlado Krstovski is considered to be co-author.

 

Dichotomies in beliefs on residents' resettlement (an analysis of Macedonian centres for social work response)

Beliefs about residents’ resettlement significantly shape the action of the providers and other stakeholders in the resettlement. They provide motivation (or lack of it) for change and simultaneously inform decisions on how resettlement will take place (or will not).

The centres for social work were asked, in an impromptu survey conducted in the summer of 2017 by MoLSP, for their opinion on ability for their residents in Demir Kapija to live outside the institution and for suggestions about what kind of care they would need. A third of the response was positive – that there are possibilities for extra-institutional care; a third was negative and a third did not answer. The response was made hastily and was not based on the characteristics of residents; it was arbitrary and indicates the attitude of a particular centre or worker of the centre who was answering rather than real possibilities for either support or capabilities of a resident to live outside of the institution. The main determinant of the response was therefore, the orientation of the centres.

Some did not answer, some were answering negatively. Most frequently, the negative statements were general: [the resident] “needs to stay in the institutions, there are no conditions for integration”. Some were oriented on potential of the residents and some on lack of services in the community (a peculiar answer, but very indicative was: “the resident is considered to be well adapted to the institution and there is no need to resettle”). 

A certain group of the centres (or practitioners) answered predominantly positively that there is a way to resettle. Mostly they suggested group homes (24 out of 60 suggestions) and ‘organised living with support’ (26/60) of which considerable number (10/60) of responses was that they would need 24 hours health care. The rest (9/60) were suggesting foster care placement and one was just generally considered able to be resettled. In regard to foster care two centres (for 7/9 cases) had written that there was no potential to live in a group home and the centre had applied for foster care. If ‘potential’ is meant for the residents, these two centres consider foster care as more potent way of caring.[1]

This response does not indicate the intensity of need of the resident nor the need or availability of support outside the institutions but the orientation of centres for social work. There is a clear division of the centres for social work that are pro deinstitutionalisation and those who are against it (i.e. do not see a possibility of resettlement).[2] This division is marked also geographically. It seems that Skopje and southern centres for social work see more possibilities for resettlement, and in northern areas, regardless the West and East, do not see these possibilities, while the centres for social work in central part of the country are undecided and silent. The intra-regional variations between individual centres for social work are very similar to the results of the analysis of geographical distribution of residents with the same centres for social work that stand out of the picture in their attitude. This division, in a way, reflects the division between the declarative orientation on deinstitutionalisation and actual reservation that are present both in politics and in the culture. Some centres for social work express their willingness to participate in the process while some share the doubt that this is possible.

In the response of centres for social work, we can discern the usual professional (and lay) beliefs about resettlements. Some support them and some obstruct. In the table on the next page, we elaborate such beliefs in more detail. Most of the beliefs that obstruct resettlement accede to deinstitutionalisation and resettlements in principle, but pose reservation about its scope. Mainly they express reservations on the ability of people to live outside, are dismissive of residents’ rights to live outside and point to a relative but permanent necessity of institutions. Like all myths, they contain a piece of truth to arrive to false conclusions. On the other hand, we have the beliefs that promote resettlements. This may be seen as utopian, far beyond existing reality. Yet, this utopia, as has been demonstrated many times is doable, it is what Basaglia (1981, 1987) termed ‘practical utopia’. These views are ethically consistent and support affirmative action, while the former prevent action, change, improvement and are ethically highly questionable.

Table 9: Beliefs that obstruct and promote resettlement

Topic	Beliefs that obstruct resettlements	Comment	Beliefs that promote resettlement
caring nature of institutions	Residents are taken care of and they would not be taken care of in the community	This belief implies that there are some aspects of care that can be performed in the institution, which for care institutions is not the case.	There is nothing that is provided in an institution that cannot be provided in community settings.
‘special needs’	Institutions’ residents have special needs that can be taken care of only in special places.	Wrong. In fact, their needs are neglected due to institutionalisation and disablist ideologies.	People with disabilities or in distress have the same needs as anyone; they need special attention and additional support in satisfying them. Needs can be taken care of in the community settings in the best way.
necessity of institution	“Some people will always need institutional care”.	This belief accedes to the imperative of DI but relativises its scope. It is true that some people need more support.	all people have the right to live in the community regardless the intensity of disability. Some people need, however intensive support to do so.
skimming	More able residents have priority in resettlement, less able are bound to stay in institutions.	This is a ‘natural’ observation, seemingly self-evident. It is false, however, on ethical and practical count. It is discriminative and causes arrest of the DI process.	Residents who have intense support needs have to have special attention and be in the second to the first echelon of the resettlements.
independent living	People with disabilities cannot live independently.	This observation is based on misconception that ‘independent living’ means either living alone or being able to take care of daily living activities by oneself.	Living independently is available to anybody if provided necessary support to make decisions and enact them. Right of choice and to make decision are the basic human faculty that has to be enabled to everybody.
need for preparation	In order to live in the community residents have to undergo thorough preparation to learn the skills of living in the community.[3]	It is true that preparation is needed. However, it should not take too long and should not be directed primarily to the residents’ abilities, but similarly to ordinary life focused on the new arrangements.	Resident should be included and involved in the preparations of their new abode from the very start. They should be main creators of the new environment. Reluctant residents should be encouraged by the visits and outings.
Intermediary structures.	Group homes are seen as deinstitutionalisation, the main if not the sole means of resettlement.	It is true that GH are an efficient way of resettling residents for institutions, however, it is not the final destination and should be considered as transitory solution and temporary abode.	For real inclusion and independent living another ‘technology’ is needed that is more personalised and that allows care provision where somebody lives – i.e. at his or her home (personal planning, assistance, home help etc.).
right and DUTIES ideology	Residents (or people with disabilities in general) have to have their rights acknowledged, but they must also acknowledge their duties.	This self-evident truth is uttered with intention to diminish the importance of rights, of which the residents were deprived.	Unconditional conception of the right to live in the community and will to enact all the human rights derogated by the institution. Reading of people’s desires and wants as the expression of rights.
‘medical’ model	People are in the institutions because of their defects that need to be treated.	It is true that some residents have a medical condition, but the main reasons why they are in an institution are that they deviate from the norm and because there is not enough support available outside.	The deficit in experienced distress is social and not personal. We need to create possibilities for people to live with people and the community; society has to learn how to live with these extraordinary people and not the other way around.

Claimer: This blog is intended as a part of Situation Analysis and Assessment/ Evaluation Report of Implementation of National Strategy on Deinstitutionalisation 2008–2018, which will be soon presented to the public within the EU framework project Technical assistance support for the deinstitutionalization process in social sector. For this blog, Vlado Krstovski is considered to be co-author.

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[1] Generally speaking, it is usually considered quite the opposite – that group homes have more potential for more intensive care. Nevertheless, in principle it is not the matter of the form of care used but how intense we make any form. Both foster families and group homes can be of low or high intensity – in group homes apart from special equipment it is a question on number and skills of the staff, in foster families it is a question of training and expertise of the fosterers (specialised) and of the amount of external support to the family.

[2] It is difficult to speculate what absence of response indicates. Does it indicate that these centres for social work do not know what is possible, or they do not dare to say – they relegate the responsibility to the MoLSP who asked the question – or they are not decided whether moving residents out is a good idea.

[3] One of the recommendations of the Ombudsman is to continue the process of deinstitutionalization by including mandatory preparatory phase period for the users. This recommendation is coming after ‘one user in the process of deinstitutionalization was transferred to a community care centre, and he could not adjust to the new conditions and was returned into the special institutions’.