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.

I Don’t Do Vulnerable

More and more I see a lot of our kids’ behaviors as desperate attempts to avoid being vulnerable.

Priscilla tells me she does not care about her foster parents. Why do I keep asking how she feels about their divorce? Nothing that happens with them affects her, why would I imagine it would? They are just people she happens to live with.

Joey, a boy who is small for his age, enters the unit insulting everyone, making death threats, talking about his gang affiliations and the weapons he claims to have hidden in his room.

Aaron is scheduled for discharge. He becomes aggressive and angrily attacks his favorite child care staff.

Katie is desperately hurting herself, refusing all offers of help, screaming that she needs to go to the hospital shortly after moving to a new group home. She finally says how unsafe she feels the place to be, the locks do not seem secure, it is in the middle of no where, who knows what the neighbors are like, and she’s not all that sure about the staff.

I think we can go far by looking at every episode of aggression we see and think: fear. When we observe unexplained anger, look for anxiety.

The video "Multiple Transitions: A Young Child's Point of View on Foster Care and Adoption" available from The Infant-Parent Institute is a profound and moving story of the child welfare system from the child’s point of view. One part that has always stayed with me is:
"Did I mention how much I am growing to hate smallness, and weakness and defenselessness? It's getting so the only thing I know how to do is to just be as tough as I can, and to try to rub out smallness and weakness wherever I see them:
In the kittens that get hung by the clothesline in the backyard and squished with a tennis racquet.In the babies in my recent foster homes who turned up scratched. In my own Self, which I attack, particularly when I am feeling small or scared, and I need to beat myself into more toughness."

Our kids have seen weakness and where it leads. They have been vulnerable. They have seen their mothers beaten and bleeding. They have been too small to stop the hitting. They have been molested and been unable to protest. They have had it with being too small, too weak, too powerless, too vulnerable. Now they are going for power and protection, whatever the cost.

So what does this mean for us? Try to keep the vision of the hurt little child in your mind’s eye when you relate to the raging teen-ager. Validate the anger and (when you can) identify the fear underneath, and validate that. Understand that the child has real and necessary reasons to hate the softer feelings. Mostly create a caring and respectful environment in which the child can relax and feel safe enough to dare to share how scared she is.

And this will be the priceless gift that you can give these kids.

One of Those Scary Nights

I was expecting eighteen people from the Department of Children and Families Juvenile Justice Division for a presentation on the Restorative ApproachSM. As I was arranging the room, checking on the food and preparing the brochures I began learning about the previous nights’ problems.

It all started with boyfriend issues, and then rapidly escalated from there. One girl pulled the fire alarm, one ended up in the emergency room. The Program Director had to come in to help the girls calm down.

I started to wonder- am I a fraud here? I am teaching all these people about this new approach, and yet we experience a night like this. We have just been enjoying a period of relative peace and calm with the girls- why did this happen? When I do training I teach that staff should not judge their work by whether the kids act up. Judge the night instead by how they, the staff, act, and whether they use the Attitude (courtesy of Daniel Hughes)- playful, accepting, curious and empathetic. Do I actually believe this?

As often happens, I learned from our child care staff. During the presentation the Girls’ Unit Supervisor Karen Pac began to talk about the differences she experiences during a crisis since we began the Restorative Approach. Staff are warmer and more compassionate with the girls. The emphasis is not on the rules, but on helping the girls calm down. If Katie wants to take a shower, although it is not 'shower time'- let her, that is an excellent de-escalation technique. The team of therapists and staff works closely and calmly together. The team concentrates on reaching out to the girls- what is the matter? That approach allows Robin to switch away from anger at her boyfriend and Nicole who has talked to him and the staff that won’t let her beat both of them up. She begins talking about her father, who said he was going to become re-involved in her life and has disappeared. Now she is crying instead of yelling and threatening. Staff are next to her sharing and validating her sadness. The next morning, the conversation centers on what is happening in the girls lives and better ways to help them. Education staff comes to the unit to meet with the girls and gauge their mood, to make plans with them for entering school (where of course the boys are) and becoming students. The girls are calm and able to attend school. Life goes on.

Our Boys Unit presented a skit for our visitors in which they act out 'before' and 'after' we switched to the Restorative Approach. The situation they chose this time was Steve who had not done his homework and was supposed to be in his room completing it. Instead he was sitting in the lounge refusing to move. In the 'before' scenario, staff concentrated on the fact that there was a rule and Steve was not following it. We must be consistent. We must focus on compliance. The therapist stood near by, but she was not relevant when the goal was to get Steve to do as he had been told. This situation rapidly escalated into a restraint. In the 'after' scenario staff asked Steve what was wrong. They noticed that he had been acting differently all afternoon, had been withdrawn and sad. They called in his therapist. They ignored the fact that he was still in the lounge. Soon Steve began talking about what was troubling him, went for a walk with his therapist, and then easily finished his homework.

These kids come to us severely damaged. They have no ability to manage emotions, and every small setback escalates into despair and panic. A problem with a boyfriend evokes all of their many devastating losses. We cannot expect that we will have no crisis’s, no emotionally over-wrought nights. Instead, we can change how we act in those times. We can stay emotionally regulated ourselves so the children have a chance of regaining emotional regulation. We do this by having a plan and through strong teams. We can shift our focus from rules to compassion. We can concentrate on helping kids calm down. And then we will experience crisis that are shorter, less destructive, less frequent, and that provide opportunities for growth for our children.