Saturday, September 11, 2010

When Chaos Strikes

It may be a call from our licensing agency, concerned about the number of incident reports. It may be reviewing our quality improvement numbers. It might come from staff complaints, or from all the meetings and discussions and panic among the team. But somehow we become aware that one of our programs, cottages or units is not doing well. Chaos has struck. There are an unusually high number of incidents such as restraints, runaways, hospitalizations, staff and child injuries, police calls, negative discharges or other signs of dysregulation. What should we do? Where should we start in our attempts to improve the treatment environment?

Usually these times are accompanied by a cry for increasing the severity of consequences. As staff feel more frightened and out of control, they reach for some sense of power. They turn towards more punitive responses as a way to feel in control and powerful. Similarly, the children are feeling frightened and out of control. They turn to violence, aggression and threats to give them a sense of power and control. A destructive cycle takes place.

In such times it is hard to take time to step back and think about what could be happening. Yet it is during these difficult periods that we most need to examine the patterns, think about how we understand the symptoms, and take measured, careful action. Also, in periods of crisis the very things that will help prevent crisis behaviors tend to disappear. Because staff are handling crisis’s or talking about them, regular activities are not done, routines break down, individual time for the children with their therapist or the staff is cancelled, and everyday positive interactions decrease. It is essential, but very difficult, to reinstate routines and activities during crisis times. Relationships, predictability, and positive activities are our most powerful interventions.

There is a tendency to blame the chaos on one or several particular youth. If we could only get rid of Marci! Joshua needs to be discharged, he needs a place with more structure.

However, as we consider what may be going wrong, staff related issues are the first things to think about. There are many staff problems that can result in program problems. All of these result in a feeling of less safety for both clients and staff, and thus create a greater need for control and aggression. Some of these are:

o An influx of new staff, not enough training
o Staff splits and tensions: different groups such as therapists/childcare staff/teachers; first shift/second shift; etc. are not getting along, blaming each other for the problems, and not talking about their differences directly.
o Therapists are staying in their offices, are not active on unit, are not in the middle of crisis’s, and are not working closely with child care staff to examine the meaning of the behaviors.
o Vicarious traumatization and no way to talk about it or take care of one’s self and others; no processing of the effect of painful events on the staff; over-working staff
o Paralysis created by not understanding new approach: at times when programs change their approach, child care staff become paralyzed. They know what they are not supposed to do, but they are not sure what to do instead. So, they ignore behaviors and don’t engage with the clients; instead they stand by feeling helpless as a child escalates.
o Understaffing: all programs have had experiences with times when we have open positions, and the staff we have (bless them) are working extra shifts and are extra exhausted. Supervisors may be working shifts and having little time to interview potential new staff. It is hard for anyone to have time to think.
o At times a culture develops in which staff do not interact with clients. They stay in the staff office, or (against policy) text their friends on their cell phones. They institute “quiet hours” or other times the children have to be in their rooms. This weakens the relationships that are the building block of treatment.
o It is amazing the power that one toxic person can have on a team, especially if that person splits staff and is underhanded.
o If the unit leadership is not strong, it is hard to address any problems. The position of unit supervisor is often filled by promotion from child care staff. This person is expected to manage complex staff issues and agency requirements. Often, they are not given adequate management training or supervisory support. This is a crucial position that needs many resources.

If we come to the conclusion that staff issues are at the center of our problem, what can we do?

This first thing is to talk about it. Bring any issues into the open. Bring groups together and hash out differences. Of course, this is hard to do when we are in the midst of problems, but it actually is our best way out. Part of the discussion should focus on staff’s emotional reactions to recent events, and their vicarious traumatization. Pain shared is decreased and better tolerated. Loss of hope and cynicism should be addressed directly. Another intervention could be training: do we need to train more on our new method? On management and supervision? On policies and procedures? There may be staff that must be addressed individually in supervision, perhaps placed on a specific performance improvement plan. And we may need to involve more agency resources in hiring.

Another area to look at is the schedule and structure of the program. It can be helpful to look at the program’s serious incident reports to search for patterns. Are there specific times, days of the week, staffing patterns that correlate with the most incidents? One must be careful in interpreting these results, as many factors can contribute to them. Still, such analysis can provide a place to start. Some trouble areas can be:

o Not enough structure or activities, too much down time, TV or electronics time, or time when the clients are forced to stay in their rooms. For clients with racing, hopeless and despairing thoughts, these times can feel awful. The client then will do something to distract himself from his thoughts, such as cause a commotion.
o One unit that did such an analysis discovered they were scheduling high energy gym activities right before bed time, and then having many problems while trying to get the clients to sleep. They reduced restraints by instituting quiet activities in the evening.
o The children become anxious in situations with unclear expectations, unpredictability of schedule, and confusion between staff about what happens next. Planned schedules that are posted for all to see help the children feel safe.
o Too much noise, activity, chaos can be overwhelming to clients.

If an analysis reveals patterns to the problems, we can change the programming and see if it helps.

Of course, some of the source of program distress is client related. It can relate to:

o A large influx of new clients
o Negative events that have affected clients and made them feel less safe, such as observing an out-of-control event that required police intervention.
o It is important to probe for secrets, things that may be going on that we do not know about. Sexual acting out and/or bullying and intimidation are prime candidates. Getting the truth out in the open can begin a change and a healing process that will result in greater safety for all.
o Individual or collective losses, such as staff leaving, especially those that have not been discussed or grieved, can lead to acting out
o The children are constantly facing overwhelming Individual life stresses
o All teams know that certain times of year, i.e. school starting or holidays, are difficult for the clients and thus lead to many symptoms.

In these cases, we may need to be active advocates for the clients. Again, talking collaboratively with the clients about what is going on, what is happening in our community, and what we want to do about it can begin a powerful and mutual process of change. And we may also need to institute extra precautions of supervision, observation and staffing to increase safety.

The common ground here is that we assume that the behaviors are happening for a reason, and the reason is not that the kids are obnoxious. We are certain that the symptoms are adaptive in some way, for the clients and for the staff. We assume that everyone is feeling unsafe and is doing the best they can to protect themselves. We start from these assumptions to think about what could be going on, and then to take directed action to enable everyone in our community to experience less pain and more joy.

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