Southern Oregon Adolescent Study and Treatment Center, in Grants Pass, Oregon, offers residential and other intensive treatment services to boy and girls from the region. For a period lasting several years, the culture of one of our residential units (the Merlin program) became corrupted. This paper describes what went wrong and how things got fixed.
SOASTC was founded in 1977 as a 12-bed program for boys, ages 10 “17 who had serious behavioral and emotional problems. For 20 years it operated from an object relations perspective, with lengths of stay averaging two and one-half years, and with a very intensive, cloistered treatment culture. The program enjoyed a unique model that had clinicians fully active and involved in milieu life. Distinguished visitors and lecturers, including Bruno Bettelheim, James Masterson and Paulina Kernberg praised the richness of the effort and the texture of the environment. The model changed beginning in 1997, partly in response to new thinking about the role of residential treatment in a system of care. At that time we began reducing lengths of stay, and focusing more on family and community involvement. Also at that time we added a second program “one that provided short term residential assessment services to a regional adolescent population. Currently SOASTC runs four programs: the two residentials, a treatment foster care program, and one that offers intensive home-based services. We remain relatively small, with a 3.5 million dollar annual budget and a staff of around 80. On a given day we serve around 45 youth and families.
A culture of fear
The cultural erosion that occurred in Merlin over the course of several years was insidious. However, by 2002, the program was in dire straits. Incidents of restraint and seclusion, always a reflection of the state of health in a culture, were skyrocketing. There were frequent runaways, and high rates of property damage and vandalism. The living environment, once pleasant, homelike and well maintained had become seedy and rundown. Pictures and wall hangings had been destroyed and not replaced, paint was peeling, the furniture looked shoddy and the place smelled of urine. Morale was terrible. For years the program had experienced very few staff departures. Average tenure for childcare staff was 8 years. But now people began leaving in droves. In 2002, the turnover rate was . Rates of tardiness, staff injury, workman's compensation claims and sick leave were elevated as well. Staff talked about experiencing a sense of dread as they drove to work.
Looking back, there were several reasons for the decline in the program. One involved leadership issues. When the agency began to expand, energy and involvement that had always been directed inwardly into the culture turned outward. There was general excitement about expansion, new programming, etc., Long-time staff who had served as the glue that held things together, now embarked on new endeavors. The original program languished. At the same time, the staffing model changed. Clinicians were pulled out of the milieu in order to focus more on family and community work. Childcare workers who were unaccustomed to being the buck stoppers were thrust into supervisory positions without training or support.
Routines and structures eroded, expectations became unclear, and inconsistencies from staff to staff and shift to shift became increasingly apparent. A culture of fear emerged. Children and youth entering residential treatment have frequently experienced violence, abuse and neglect in their pasts. The world for them is unsafe and unpredictable, and they are driven to recapitulate their representational models in their words, thoughts and actions. In order to be effective, the treatment environment must offer a safe haven that offers an implicit challenge to the notion that the world is dark and fearsome.
When an environment is unable to do this, it can become retraumatizing to these children. Fear begets reactive, hyper aroused responses that contribute to turbulence, which generates fear, in an escalating cycle of violence. Milieus can cross thresholds and arrive at tipping points in which fear becomes contagious, in which the children act out their fear, and in which staff resort to reactive, coercive or punitive responses in a vain effort to keep the peace.
We saw this happening in Merlin, and didn’t know what to do about it. In searching for a way to break the cycle, we initially made several blunders. One of these involved efforts to assign blame. Staff weren’t doing their jobs, the administration wasn’t supportive, the admissions department was taking the wrong kinds of kids, the supervisors weren’t consistent, etc. One of the symptoms of an unhealthy organization under stress is lots of finger pointing and little accountability. Another misstep involved efforts to beef up security. The theory held that the kids were harder these days, and we didn’t keep them long enough for them to form identifications. The solution then was to fortify. We added locks, built fences, added a second seclusion room, and in general got caught in an escalating arms race. The new locks were picked or broken, the fences straddled, and at times we needed four seclusion rooms. A final error was to send a message to staff to keep “hands off” and avoid restraint and seclusion at all costs in an effort to get the numbers down. To staff this meant laying down their weapons and surrendering in the face of enemy attack “they were left feeling powerless and resentful. To the kids this seemed to mean there were no limits left at all. Paradoxically, numbers of adverse episodes continued to rise.
A confluence of several factors led to an eventual “aha” experience and to a way out of the morass we found ourselves in. We realized that a sizeable disconnect had arisen in the culture. We had always known that the relationships we developed with children and youth could be used to solicit appropriate behavior, encourage positive identifications and motivate change. However, our focus in the past several years was increasingly behavioral, and staff had become, in effect, behavior cops instead of guides, coaches and mentors. We conducted a root cause analysis, which concluded that there were fundamental problems with program design and philosophy that underlay our problems with restraint and seclusion. We sent several staff to the Child Welfare League’s conference on restraint and seclusion in 2002, and they came back to report the innovative measures other programs had taken to improve quality of treatment effort. In the end we came to the realization that it’s all about the culture.
A culture of hope
How do you change a culture? We decided to initiate a cultural improvement initiative that would be an effort to improve treatment environments in all of our programs, not just in Merlin. A task group formed to guide this effort, and developed the following mission statement:
“To enhance agency wide treatment efforts by involving staff, parents, youth and community partners in a change process within the organization. By developing cultures that foster our youths” potentials we hope to achieve positive identifications, reduced need for coercive interventions and improved outcomes."
With input from staff and kids, we selected broad areas in which there was room for agency-wide improvement, and launched the KINSHIP initiative. The initiative defined seven broad improvement areas, which were then individualized, designed and implemented uniquely in each program. The Kinship committee has met regularly to monitor progress and compare program notes. In the 15 months since the initiative was introduced, many improvements have occurred. What follows here is a brief description of the rationale for the various initiative elements, and how they were applied in the Merlin program.
KINSHIP is an acronym for Key values, Interactive/active environments, Nurturing, relational approaches, Strengths/skills for success, Healthy environments, Individualized treatment planning, and Professional Staff/Parents.
We wanted to shift from focusing on rules to focusing on values in our programs, since the latter were a way of informing appropriate behavior that could be translated into any setting. We decided to identify seven values that could be used to guide all behaviors and serve as a model for all interactions. Staff and clients came up with a long list of possible values and then through a process of elimination and voting, winnowed it down to the following: fairness, empathy, responsibility, honesty, kindness, respect and humor. In Merlin, these words are posted in clever and attractive designs all over the campus. Most kids are able to name all seven values and define them. A “value of the week” is highlighted and woven into skills groups, action assignments and incentive points. A plan is underway to develop a purely values-based levels/incentive system.
There are milieus in which a customary scenario has the kids huddled around a television while the staff stand behind them, monitoring behavior and chatting with one another. In the past 15 months, the Merlin treatment milieu has come alive and busy with developmentally appropriate, gender-specific projects, chores, recreational pursuits and leisure endeavors. Staff and kids are engaged in meaningful pursuits and ongoing dialogue. Teaching moments abound. Each staff person has been encouraged to share his or her interests and passions with the kids. Children have a stake, an interest, and a say in how the day unfolds. Pets are welcome, plants are cultivated, there is music and art activity. Staff espouse the mindset, “play your way through the day”. Music, art and woodshop classes have been introduced. There is lots of outdoor time. Everyone has a bike. Television and Gameboy time has been circumscribed.
Nurturing and Relational Approaches
Most people who are drawn to childcare work have a strong nurturing component to their characters. When an environment becomes too chaotic staff become cops and this trait can get lost. A program can establish an atmosphere, though, in which children feel valued and cared for, and in which staff efforts to remain nurturing are reinforced. In Merlin in the past year there has been much talk of keeping the focus on being nurturing and relational. The concept has entered the language of the program and is referred to frequently. Changes in practice guidelines reflect this focus: e.g., greatly reduced use of confiscation as a consequence, alternatives to monetary fines for property damage, using relationships as reinforcers. Training and discussion has occurred about using appropriate use of touch, the importance of play, and avoiding power struggles. We have revised all our milieu guidelines with a view to avoiding power struggles too: e.g., must we insist that a boy eat his spinach to get dessert? Merlin boys are encouraged (especially through a weekly Community Living Group run by the program manager) to participate in program design activities, to recommend changes to guidelines, and to feel a sense of involvement and responsibility for everything that happens.
We have used Miller and Rollnick’s book, Motivational Interviewing, as the basis for a series of all-staff trainings about how to engage with children in the moment-in-time to deescalate situations, and encourage behavior change and smart decisions without using direct confrontation. The techniques or rolling with resistance, expressing empathy, developing discrepancy and encouraging responsibility fit perfectly with staff-wide efforts to develop and refine relational stances with clients, and give staff practical tools and advise to use on their shifts.
The agency’s treatment philosophy has shifted in recent years away from our psychodynamic, object-relations foundation toward a strengths/skills perspective. We have come to realize that while there is not much we are able to do to mitigate innate or historical risk factors in children, there is much that we can do to develop or strengthen protective factors for them. Increasingly we have come to recognize that good treatment involves good case management, which in turn means developing and enhancing supports for the child and family. Additionally it involves assisting the child and family in acquiring new skills that they can put to use in a practical sense. In Merlin, our Care Plans are based on strengths/needs assessments: if we could provide this child/family one or two tools that they could take with them and use to make their lives smoother, what would those tools be, and how can we provide them? We are in the process of developing an agency-wide skills/based curriculum. Kids are spending much more time in the community “at public school, on home visits, playing little league baseball, enrolled at the Boys and Girls Club, participating in Habitat for Humanity, etc. Our clinicians are working with schools and social service agencies, paving the way for a child's return to family and community. This “can-do” focus, and positive, pro-active orientation is more uplifting and effective for all concerned that the old, pathology-centered model.
The appearance of a program facility establishes the tone for what occurs within it. In its “golden era”, Merlin had been exceptionally homelike and comfortable, with tasteful furnishings, art on the walls, and generally well-maintained buildings and grounds. Residents appreciated their surrounds and felt honored and valued by the environment. Property damage was a rarity. Now, under the direction of the new manager, the Merlin group put much energy into restoring the environment. Staff volunteered many hours of personal time to paint and refurbish the rooms. One of the quiet rooms was converted to an attractive, kid-friendly comfort room where residents could retreat to pull themselves together. The rec room, spacious, but by now dank and shabby, was given a major facelift and became a kind of showcase room that everyone could enjoy and take much pride in. New furniture arrived. Holes in the wall were repaired immediately. It became “uncool” to disrespect the environment. Kids were eager to give tours to family members and visitors, and took pride in showing off the facility. They even begrudgingly agreed to keep their rooms tidier. The change in the appearance of the facility was certainly the most noticeable, but also probably the most important contributor to the change in culture that occurred. There is great danger in the position that holds, “don’t bother trying to make things nice, the kids will just trash it.” This becomes a self-fulfilling prophesy.
Individualized planning had been occurring within the agency for a long time. The Kinship Initiative stressed the importance of getting people from outside the agency to participate in the planning process, getting the child and family involved at the planning table, and building plans based on identified needs and strengths. There was a time not so long ago when Merlin residents were unable to tell you why they were in the program or what they were working on. Now most are able to identify goals and objectives that they have had a hand in creating, and are able to tell you what needs to happen in order for a successful discharge to occur. Rather than being passive recipients of “treatment”, they are more active participants in their own planning. This is true for their parents as well, and for other community members (teachers, child protective workers) who will have a vested interest in the child after discharge. Increased commitment and investment by all parties means better outcomes.
We have developed an instrument we call the Teaching and Management Plan that staff use to plan individualized intervention strategies. Staff gather in brainstorming sessions around a particular youth. His strengths and needs are identified. The youth’s “internal model” is depicted “how he perceives himself in relation to his world. Triggers to problem behavior are listed, followed by discussion of “jamming strategies”: interventions staff have found successful in derailing the escalating cycle of behavior.
Parents and Professional Staff
A change in Merlin that has happened partly as an outgrowth of the Kinship Initiative involves parent participation in the agency, the program, and the milieu. Visiting hours have been abolished, and parents are free to come and go as they please. On any given day one or more parents are actively engaged in milieu life, hanging out with their child, engaging in group sessions, or shadowing staff to observe and practice child management skills. Parents have seats on the agency’s Board of Directors, Advisory Committee and Family Focus Committee. The agency offers support groups and training/ teaching opportunities for families. Parents are able to call their children on an 800 number, and the agency will provide childcare for siblings, cover meals and transportation costs, and do other family friendly things to encourage and support involvement in the program.
Home visits occur routinely, and therapists and other staff make regular trips to the home upon invitation. A program is only as good as its staff. Issues of training and morale are central to maintaining a healthy staff group. One of the problems Merlin struggled with during the crisis times was staff attrition. People felt overwhelmed by the demands of the job, found few rewards in the work, didn’t believe they were making a difference in kids” lives, realized that they could sling hamburgers for as much money, and left. New staff were untrained, inexperienced and ill-equipped, and they left too. The program’s pool of seasoned veterans shrank. To address the problem we developed a 12-week, 48 hour training and orientation program for all new staff, that provides child care basics, with an emphasis on relational approaches, avoiding power struggles, etc. The Gus Chronicles by Charlie Appelstein is required reading and serves as the focus for discussion groups. Weekly “Noontime” trainings over lunch conducted by senior staff, focus on hot clinical issues, and are mandatory for all staff. A quarterly daylong agency-wide training has been initiated, and is usually led by the Executive Director. The emphasis on training has led to an improvement in the quality of the work performed in the milieu, and further relaxation of the program’s crisis orientation. This in turn has led to improvement in morale, and substantially less turnover. The program’s strengths/skills focus applies to staff as well, and each staff person's attributes and contributions are honored and valued through various awards and celebrations. A sense of solidarity and camaraderie has been restored.
In March, 2003 Merlin experienced 120 incidents of restraint or seclusion (.30 per client day). In July, August and September of this year, those numbers were 3, 5 and 4 (approx .01 per client day). There were 27 runaway incidents in March, 2003, and 2 in September 2004. In the first quarter of 2003, 40% of discharging residents showed at least a 10 point improvement in CAFAS scores. In the third quarter of 2004, 78% showed this improvement. In the six month period between June, and December, 2001 there were 28 staff resignations; in the six months between March and September, 2004 there was 1. Staff, client and parent satisfaction surveys all reflected significant increases in level of satisfaction in all areas.
In summary, a positive program culture and milieu environment that had eroded over time due to entropy was restored through a systematic rebuilding process that identified key variables and prescribed specific solutions. The role of leadership in this process deserves special mention. It is interesting how a program assumes the attributes of its leader. As we searched for a competent leader for the program we encountered several who were not up to the task. One manager had difficulty taking a clear stand on issues and during his watch guidelines and structures eroded. Another was highly disorganized and his program became increasingly chaotic and undisciplined. Another had significant authority issues, and during his tenure rifts developed between staff, kids and administration. The leader who has spearheaded the changes described in this paper displays characteristics that have shaped the current program: a genuine affection and regard for the kids, a surplus of energy and enthusiasm, an ability to remain calm in crisis, a sense of humor, and a charismatic style that elicits best efforts from her staff. Effective residential treatment is about creating a positive culture, and positive cultures can be created.
This feature: Focus Adolescent Services: Bad milieu, good milieu: restoring a culture of hope. http://www.aacrc-dc.org/public/pdfs/BAD%20MILIEU.pdf Southern Oregon Adolescent Study and Treatment Center