Sunday, November 26, 2006

When Programs Have Problems…

Recently we noticed that one of our units, the Acute Unit, was experiencing an increase in the number of restraints and seclusions. This unit provides excellent treatment for extremely damaged children ages five through twelve. The unit has fourteen kids at a time and is co-ed. This was our first unit to transition to the Restorative Approach. The program has a high reputation for attachment focused treatment.

The first step in responding to a problem is to notice it and pay attention. It took us longer than it should have to take the increase in restraints seriously, analyze the data and begin discussions with the staff and with the kids about what was going on. When a program is in crisis mode people’s time is eaten up responding to the demands of the moment. This stepping back and thinking is especially hard. But it is also especially necessary. The staff of the unit described a feeling of relief when the restraint numbers were reported to them- so that is why I am feeling so tired and drained! Finally someone is paying attention!

We analyzed the reports as to time of day, staff involved, reason restraints started, which kids were involved, etc. and then scheduled a meeting with the entire team and administration to discuss the problem. The meeting tone was not "what’s going wrong down here?" but instead "what help do you need?" However, by the time we had the meeting the team had already reduced the restraints and seclusions and changed the unit situation. So, instead we discussed how they did it. These discussions are as important as problem solving. They serve to underline and re-enforce the changes made, give employees recognition, and further unite the team.

So how did they change the unit atmosphere and reduce restraints and seclusions?A therapist from the team led training on "The Attitude" from Daniel Hughes (playful, accepting, curious and empathetic) and everyone committed to using this through out the day.

The difficulties had partly been caused by staff turnover- several people had left at once and the unit had been operating with open positions. So now that the positions were full, they had activities to create the new team, get to know each other, and discover each other’s strengths and interests. That way each staff could lead from their strengths. An example given was staff starting activity groups based on what they liked to do. As one child care worker said: "don’t have the crafty people leading the sports". The retreats and trainings focused on self awareness, understanding one’s emotional responses to the kids, and asking for and receiving help. They spoke proudly of their ability to be honest with each other and share their feelings, let each other know when they are burnt out or depleted.

Analysis of the data revealed some times when restraints were highest, notably after dinner. So the team changed the structure of that time period. They divided the kids into two groups for dinner (instead of all eating together), eliminated "siesta time" when they were supposed to be in their rooms but didn’t want to be, instituted calming and relaxation groups, and decided their would be no gym or active games after 7:00. They also added more structure and planned activities on the weekends, deciding in advance how to split the kids up to break up difficult combinations.

A large turnover in kids had also contributed to the restraints and seclusions. The data showed that only 4 of the 14 kids contributed most of the incidents, and that both the frequency and duration of restraints decreased over time for each of them. So the unit decided to adapt ways of getting to know new kids sooner and better, such as by assigning individual staff to spend time alone with each child. They reported that when they concentrated on this they more quickly learned how to help the child avoid escalation. One example was a kid who could accept a tight hug and avert a restraint.

We also discussed: what are other indicators of how unit life is going, in addition to restraints and seclusions? People identified- there is more laughter. We see the positives in the kids and in each other more clearly. We say more complimentary things to each other. We feel closer to each other. We have more fun with the kids.

The unit management now plans to watch all these indicators, including restraint and seclusion numbers, more closely and report them in staff meetings weekly. There is a tendency that when things get better we drop the practices that made them better, such as carefully planning the activities of each shift. The weekly discussion will guard against this. Also, key times such as a grouping of discharges and new admissions, or several very young kids coming at once, have been identified. When such a time approaches, staff will implement special active plans.

It was so moving to see a team of people realize a problem, take it on, and change it, through using the fundamental building blocks of this approach: relationships, the Attitude, planning, and thoughtful understanding of our traumatized kids.


Anonymous said...

I am the parent of a child on the Acute Unit. I still notice quite a few restraints and seclusions. I also still sometimes see staff engaging with children in a manner which escalates the situation. I hope staff are getting continued training and support, especially weekend and per-diem staff. The Acute Unit is a good Unit, probably one of the best in CT. I am pleased that Klingberg is taking this approach with the children. If I could add a suggestion, I feel all staff and therapists should take the words Manipulative and the child can control it out of their vocabularies. All 14 of those kids, who I have gotten to know, show their feelings and anxieties in many different ways. I think that the words manipulative and the child can control it send a poor message to the children, that it is their fault and also doesn't help to engage the parent in the child's treatment,leaving them feeling to blame. Sometimes we forget how fragile parents are too. The only two staff who really keep the parent's feelings in mind, I feel, are Dr. Buzz and Renee Yankowski, both of whom focus on the child and families strengths rather than their symptoms. Keep up the good work.

Patricia Wilcox, LCSW said...

Thank you for your thoughtful response. I am glad you are having a largely positive experience with the AU. You have pointed out some of the most important and difficult training issues in residential treatment. The issue of the use of the word "manipulative" I have written about extensively in this blog, and it is an important one for staff training. Risking Connection focuses strongly on this concept. Making sure part time and per diem staff get training and support is another crucial and difficult challenge. Glad you are joining us in the journey of improving the treatment for these kids. If you have other questions or concerns about the AU I hope you will discuss them with the AU leadership.