Bad milieu, good milieu:
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
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
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.
Nurturing and Relational
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.
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.
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
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 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.