When CPS Fails – Staff Shopping

In his book, The Explosive Child, Ross Greene explains that many of the problem behaviors seen in children stem from lagging and lacking skills.  He contends that what we see is not simply defiance or maladaptive behavior.  Rather, these behaviors represent an underlying skills deficit.

With this, I agree.  Children end up in treatment because they struggle to interpret and then navigate basic social cues and norms. It serves no-one to label these kids as “problem children.”  Collaborative Problem Solving (CPS) creates a framework for conversations so that caregivers can begin to map and work on improving lagging and lacking skills.

However, what the CPS model fails to address is that often both are true: the child has lagging skills and he’s developed maladaptive behaviors.  He’s seen that they work in getting an immediate desire met or releasing him from an expectation.

One of the more common behaviors seen in residential treatment is “Staff Shopping.”  A parent might recognize this as when after receiving an unfavorable answer from one parent the child goes to the other parent hoping for a different response.

In treatment we’ll often see clients with high intensity, perseverations and the inability to delay gratification.  They are often used to badgering a caregiver into getting what they want.  When not receiving the answer they want, they will seek out another Staff.  Institutionalized children are especially aware of hierarchies and will often ask to speak to a manager rather than direct line staff.

It is especially important when implementing CPS in residential treatment to make sure children are getting their needs met through appropriate channels. When we allow a child to circumvent a caregiver on a basic need, we are only further cementing the maladaptive behavior, and missing an opportunity to teach or practice a skill.

The main issues we see when Staff Shopping becomes a problem are:

  • Lack of unit structure via basic expectations and maintaining consistent schedules and unit culture.
  • Lack of communication between all Staff members.
  • Managers and other Staff who work with a client, without first checking if the client is getting his need met appropriately.

Most issues in residential treatment are somehow related to the breakdown of consistent structure.  Structure is not simply a schedule, it’s a process. Managing a therapeutic milieu requires that we honor and consistently practice our processes for helping clients get their needs met.

Structure:  Basic expectations provide the opportunity for the client to practice transitions (shifting from one energy level to another), to self-manage and to get their needs met appropriately.  Examples might be Quiet Room Time, or no sugary personals until snack time.  Structure also provides the fame work that creates predictable issues, leading to more consistent interventions.

Process: Just as Staff  can’t step off the floor without communicating to another Staff, clients have to use words to express their needs, and work with the Staff available to him, not a favored Staff. And sometimes you have to wait. If a client attempts to get around working with a particular Staff, they should be redirected back to the Staff they were supposed to get permission from first.

Structure and process in action:

John is in quiet room time (QRT).  John is impulsive and struggles to remain in QRT and relies heavily on music to self-manage.  He pops out of his room frequently and can often be demanding and disrespectful to female Staff.  He often blows them off and seeks out a favored male supervisor, Tim.  John asks Staff to speak with Tim:

Staff: Dude, it’s QRT.  This is a time to self manage.  What do you need?

John: I want to talk to Tim.

Staff: Right, I got that.  But Tim’s busy.  I’d like a chance to work with you, first.

John: Fuck you, I’m going downstairs!

At this point, structure is still intact and so is the process.  But, if another Staff or Tim, engage John warmly then both structure and process are broken.  The Staff working with John would walkie to other Staff that John is heading downstairs without permission.  Staff downstairs should essentially be sterile with John and redirect him back upstairs and not meet any need.  But that doesn’t always happen.

Clients like John usually want two or three things in this instance.  One, they may be bored or be dependent on someone/something else to occupy themselves.  Two, they may legitimately be experiencing some kind of hard to manage emotion or feeling.  And three, they may have a reasonable need like a new battery for their mp3 player or want to see if their parents returned their phone call.

Regardless of their unspoken need, if we provide warm interactions and meet John’s need, we’re essentially enabling maladaptive behaviors.  This is how Staff allow a client to “Shop” for an answer they like.  Even if John is able to articulate a reasonable need to Tim, say for a new battery for his mp3 player, he needs to learn to do that with the Staff upstairs.  And he needs to build skills for getting permissions and delaying gratification.

Together, structure and process create consistent interventions that we can become practiced at having.  Because we know where kids are going to struggle, we can lead the interventions so that meaningful skills training occurs.  This means real conversations leveraging the Collaborative Problem Solving model.

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Where is the behavior modification?

Another friend is moving on.  When commenting on his frustrations in working at our facility he specifically pointed to the secure units.  “It got to the point where I didn’t want to walk onto those units.”  We both readily admit we work with the toughest children in the region.  What was wearing on him was the high concentration of youth with incredible high-risk and anti-social behaviors.  He spoke of other kids being exposed to this level of acuity and learning their behaviors.  Just to be clear, the behaviors are purging, self harm and suicidal ideation.

He didn’t even want to share this with me, “I don’t want my bad attitude to affect you, you’re still here doing important work.”  But he quickly went on “We’re not doing any behavior modification.  These kids need that too.”

It was the type of conversation that wasn’t long but covered so much ground.  We bemoaned the fact that as a culture there is a collective pat on the back for closing psychiatric hospitals and shifting so much of mental health care to outpatient services.

Unacknowledged among the accolades of progress is the pressure to get kids stable and free up the bed.  Many of our clients need long term care.  Temporary stabilization isn’t going to do much for them if they return to the same environment without increased skills to manage they lives they were given.

This happens again and again when kids return to our care after failing to reintegrate at home or adapt to foster placements or group homes.  These kids aren’t going to improve without meaningful skill building.  And this leads back to behavior mod.  We simply aren’t doing it any longer.