When a Treatment Program Becomes a War Zone

I have written before about the development of a siege mentality in treatment programs (10/06/15). In that blog I described trauma-based thinking and its effects on both the clients and the staff. I also wrote a blog post on 9/11/10 entitled When Chaos Breaks Out in which I examined how to address a program that is in trouble. I would like to revisit these issues in a systematic way here.

In this post I would like to specifically address the situation in which a program has become demoralized and overwhelmed, and is just trying to make it through the night. Programs in this state rely excessively on the use of force, restraint or intervention teams. Structure and programming are lost. The staff are in a state of fear, and just move from one crisis to another. The staff are often responding to their fear of what could happen if this situation got worse, not what is happening at the moment. The clients are not feeling safe, and thus are acting more aggressive.  For both the staff and the kids there is a sense of imminent catastrophe.

How Do Good Programs Become War Zones?

There are many factors that can contribute to the development of a battle mentality in a program. The process is cyclic and can start with any combination of these factors.

·         Influx of a new, more difficult population

·         A new type of client for this agency without enough specific training

·         Significant staff turnover, in child care staff, therapists and/or leadership.

·         Not enough training for new staff

·         Understaffing and resultant over working of staff

·         Change in available resources.

·         Implementation of a new treatment approach.

·         Lack of integration of therapists into treatment program

·         Changes in regulations governing care, such as limits on the use of restraint and seclusion

·         Serious incidents of staff assaults

Signs that a Program has Moved Towards a War Zone Culture

·         Staff injuries increase.

·         Child injuries increase.

·         Lack of structure, few activities planned or carried out

·         Inconsistent application of limits

·         Increasing numbers of power struggles leading to restraints

·         Over-reliance on control.

·         Over use of calls for assistance, relying on a paging system the clients can hear

·         Living areas look bad, damage is not repaired, areas are not clean

·         Treatment plans are not communicated or followed through

·         Staff do not feel they are part of the treatment. They do not see the connection between their work and the child’s goals

·         Therapists are staying in their offices and not interacting with child care workers or hanging out in program spaces

·         High turn over

·         Supervision does not take place

·         Individual therapy does not reliably take place as therapist is handling emergencies

·         Routines are not followed

·         Use of sick leave increases

·         People speak of the clients in hopeless, blaming terms

·         Splits occur and deepen between parts of the team, and staff blame each other and administration for the problems that are occurring. There is an “us vs. them” mentality.

·         Staff reduce interactions with clients, stay in the office more, start texting their friends during work.

·         People are not sure how to intervene when problems begin (because they know they are trying not to use restraints or rely heavily on consequences) so they do nothing and feel helpless as they watch a client becomes more and more escalated.

How Can the Program Regain Its Treatment Focus?

When an agency becomes aware that one (or more than one) of its programs has deteriorated towards a war zone operation, there are roles for each group pf people that the program may want to start immediately. Follow through mechanisms should be established to track implementation. Data about restraints, staff and child injuries, hospitalizations, arrests and negative discharges can provide reliable information to evaluate the impact of interventions.

Senior Leadership

·         Begin the conversation- start talking about what is going on and the reasons for it.

·         Convey hope in the possibility of turn around

·         Establish contact with every staff member who is hurt.

·         Speak warmly and hopefully of the youth.

·         Recognize staff achievement.

·         Remind staff about their reason for doing this work, the mission, the importance to the youth.

·         Make resources available for change effort.

·         Articulate over all program expectations, such as what is meant by imminent danger and when restraint can and cannot be used, or when to call the police.

·         Congratulate team members on their stamina in sticking with a certain child, reminding them that it is the most important thing they can do.

Mid-level Leadership

·         Lead change effort

·         Establish clear expectations and methods to measure them, and regular review periods to evaluate progress, including who will be responsible. Be careful not to let sympathy for the difficult time staff is experiencing result in a relaxation of the expectations. If there are reasons the expectation was not met, how will be overcome those reasons during the next time period?  If the administration just accepts the reasons and communicates: “oh well I guess there is nothing we can do” they are replicating the paralysis felt by staff and thus increasing it.

·         The following table illustrates some areas in which expectations can be clear and monitoring mechanisms established. This is not an exhaustive list, it is just meant to illustrate the kind of clarity that is important.

Child Care Staff Expectations	Person Responsible for Implementation	Monitoring Mechanism
There will be two planned activities per weekday and three per weekend/vacation day.	Unit Supervisor	Schedules passed in, comments written on each activity, spot checks
Each child care staff member will have a chore towards the cleanliness of the unit and will complete it on each shift they work.	Unit Supervisor	Chore list passed in, spot checks
Each child care worker will be assigned three youth as their special responsibility. They will spend at least ½ hr. individual time with each of these youth per week.	Unit Supervisor	Progress notes
Therapist Expectations	Person Responsible for Implementation	Monitoring Mechanism
Therapists will attend staff meeting weekly	Clinical supervisor	Meeting attendance sign in
Therapists will make sure that the child care staff understand the children’s goals and how that is translated into what the child care worker does	Clinical supervisor	Therapist and staff report
When a child is in crisis therapist will connect with child and staff within 4 hours or will designate someone to do so	Clinical supervisor	Observation, progress notes

Further interventions for middle management:

·         Added resources in a targeted way. For example, have a cleaning service do a thorough cleaning of a unit as soon as the staff and kids have created a cleaning schedule to maintain the cleanliness.

·         Articulate and model the expected method of interacting with the kids- be involved, caring, flexible, respectful.

·         Clinical management can be clear with therapists, from the hiring onwards, that they are expected to be part of the team and not doing outpatient therapy in their office. Teach and give examples of how to translate treatment goals into unit activities for staff.

·         Clinical management guide and model for therapists how to lead team in clinical thinking. The therapists and clinical management establish clinical thinking by responding to every attempt to discuss a problem behavior by asking: how do we understand this behavior? When we understand the adaptive nature of the behavior we can respond by helping the child to learn to meet these same needs in a more positive way. The clinicians also make sure to share the formulation with the team, to establish a treatment theme, to connect problem behaviors to past history, and to suggest restorative responses based on the team’s understanding of the skills a child needs to learn.

The Child Care Workers and the Therapists

It is counter-intuitive but the essential that when a unit is in crisis, the staff must move towards the youth, not away from them. The natural human response to harmful behavior is to move away. This can manifest by emotional distance, by increased strictness, by lack of activities, by staff spending more time in the office, or simply by frowns and disapproving looks. By their behavior the youth are telling the adults that they do not feel safe or connected. We have to make plans to increase their connection to adults. How do we do this?

·         Schedule time for staff to spend with one-to-three clients, doing a pleasurable activity.

·         Organize team building activities, using consultation from recreational therapists if available.

·         Have as many fun activities as possible.

·         Use music, dance, singing, jump rope rhymes, hand games to knit the community together.

·         Develop a cottage song, a mascot, a logo, a saying.

·         Celebrate anything good that happens, even if small.

·         Have a box in which anyone can put a note about a good thing they saw a kid or a staff do, read it out at community meetings. Give awards, but not competitive ones, ones that anyone who meets some criteria can receive.

·         Have community meetings. Have all participate. Talk about what is happening, what kind of place we want to live, what we can do about it.

·         Decrease room time. Spend as much time together, doing activities.

·         Do the kids’ hair. Have a spa night. Feed them. Do anything to care for them and make them feel better.

·         Clean and decorate the unit. Involve the kids.

·         Fix any damage. Involve the kids.

·         In Treatment Team talk about the kids that are the hardest to connect with. Review their history- why did they have to learn to put up such walls? Encourage compassion. Discuss their strengths and interests. Can staff find a way to participate in these interests with them?

·         Keep a notebook about the most difficult kids called “Moments of Hope” and ask staff to write down any good things that happen with that child.

·         Congratulate each other on the team’s stamina in sticking with this child.

·         Make specific plans to support that stamina, like trading off who reaches out to the most hostile kids.

·         Remind each other about other kids you have known who seemed to reject all efforts and later came around.

·         In treatment team develop restorative ideas for each child that are significant, require thought, and are related to their treatment.

·         Teach specific feelings management skills.

·          Use feelings management skills yourself and label out loud that you are doing so.

·         Validate the feelings behind the behavior.

·         Express an understanding that this is the best the kid knows at the time- and the hope and confidence they will learn better.

·         And tell them, and show them, over and over again, all the good things you see in them and how delighted you are by everything positive (and even neutral) that happens.

Even this partial list of interventions seems like a daunting task. It is. What is more daunting is not doing it and remaining in paralysis. A specific plan with clear responsibilities and methods of measurement will begin to create change. As people notice change, there will be an increase in hope. Hope brings the energy to make more changes. And fairly soon people will be feeling pride in their workplace again, and the kids will be gradually getting better…slowly…with many backslides…but they will be demonstrating that they feel more connected and relaxed. Then real effect treatment will be occurring.