structure

The White Board

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“Nathan” was a broad shouldered kid of 16 when I first worked with him.  It was good to get him out of the unit and active, it took the edge off him.  He was competitive, but a good sport, and enjoyed playing basketball and football.  He was well liked by his peers.  Nathan was also good looking, but didn’t seem to realize it.

This last was good.  There were girls who were interested.  But girls in treatment, well, the kind that attempted to get his attention, are sexualized beyond their years and prone to unending drama.  His apparent cluelessness saved him a lot of grief.

Nathan was fairly high functioning, as compared to most of our kids.  He focused on treatment and did not get sidelined by peer negativity.  The obvious reasons for why he was here were persistent anxiousness and impulsivity that led to outbursts.  These outbursts were usually limited to verbal disrespect and broken furniture, though he had been suspended from school a couple times.

The thing is, though, we really didn’t see the verbal defiance.  We saw a kid who responded well to structure and male authority figures.  His father wasn’t in the picture.  Nathan liked groups, participated well and really appreciated the white board. In residential treatment the white board has the day’s schedule, activities and appointments and is used to keep track of the location of clients and staff.

The combination of groups and the visual organization of the white board can have a grounding effect on kids who lag behind their peers in areas of executive functioning or internal structure.  This was really the case with Nathan.  In fact, Nathan identified this as something that would help in the home.  His Mom was willing to try this and bought a white board for when he arrived back home.

A month after discharge we got a call from Nathan.  He was upbeat and positive and reported he was doing well.  They had hung the white board in the kitchen and were reviewing the day’s schedule each morning going over what he was responsible for, such as starting dinner or meeting younger siblings at school and walking them home.  Mom said his school attendance was up and their interactions were much better.

So, when Nathan returned to treatment about six months later it was a little surprising and discouraging to find out that while the white board had gotten broken, it then wasn’t replaced.  Nathan was back, in part, due to the return of his old troublesome behaviors; getting escalated easily, not contributing in the home and school avoidance.

The underlying problem was his anxiety for the unknown and a lack of structure.  Both of those had been addressed by the white board.  It wasn’t just the existence of the white board, but the family taking the time to utilize it and review what makes it on to the board.  This external structure was a family routine that needed to be maintained.   But the white board wasn’t replaced and the new, successful habit fell to the wayside.

Something simple can make a difference

This illustrates the gap between what is identified and works in treatment and yet is not maintained in the home.  It also is an example of a time where the parent has to be willing to step up and be an adult and change and lead by maintaining the tool or modality that is improving interactions.

Resistance from parents to Collaborative Problem Solving is often the notion that they have to accept disrespect or non-compliance.  This isn’t the case.  But, what usually is the case is that parents need to modify their behavior as well.

The parent of a child with Aspergers might have to greatly modify their tone such as eliminating sarcasm.  A child who struggles with transitions might need more proactive discussions offering reminders and reassurances of what’s expected or on the schedule.  And if a kid breaks the white board in a moment of frustration, when otherwise the family has been running more smoothly than in the recent past, you prioritize replacing it without attaching a consequence or trying to prove a point by holding it over his head.

Changing habits and patterns in a family unit is hard work, takes time, and all parties need to be amenable to feedback and be willing to change.  Not just the kid.  Because if the kid is doing the work alone he won’t succeed and the family unit will continue to operate in crisis mode.

When CPS Fails – Staff Shopping

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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.

Complete Turnover

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Staffing issues continue to impact the quality of care in mental health.

5 years, 1 year, 9 years and 2 years.  There has been a rash of people announcing they are leaving.  Some to other jobs within the organization (5 and 9).  One to a better job outside the organization (2) and the other for relationship issues (1).  Though behind each decision to move on lies a common undercurrent: exhaustion.  We continue to lose quality people at an alarming rate.  This in the face of a pay raise that was not insignificant (for me, who has been here 6 years, it was a $2 raise).

Some of the comments I’ve heard or read as people say their good-byes; one marveled “I get to have a lunch break!” And the relief she can do so without a walkie attached to her hip.  “Where is the behavior mod? With the high concentration of acuity, these kids are learning unhealthy behaviors from each other.” Perhaps the most telling comment was from the person leaving after two years; “I’m the last member of my original team.”

In two years and entire team has been replaced.  The truth is, however, the turnover is worse than that statement would indicate.  A complete team rarely lasts more that three or four months.  The constant churn of Staff is a persistent problem affecting the treatment we offer our clients and the morale of Staff.

We are forever rebuilding teams and establishing working rapport.  Working rapport is the ability to recognize the strengths and relationships of your team members and then be able to leverage them in working with clients.  In treatment this also means creating the environment for consistent interventions. But if there is no working rapport, then we are reduced so much more quickly to crisis management.  It’s not good.

In one primary treatment modality, Collaborative Problem Solving (CPS), the goal is to work proactively with clients.  But if we have no working rapport, our institutional memory suffers and our unit culture degrades.  When floor staff lose the support of structure, we fatigue more easily, we become reactive and we slip into forcing expectations or dropping expectations.

We move from proactive conversations to reactive solutions that frequently have little buy-in from clients and fail at building skills.  And, for institutions who have been in the business for decades, we should be doing a better job, we should be better equipped to follow through on treatment plans.

So what is the solution?

Outside of wholesale changes to how we fund mental health, I offer two.

Perhaps the most important would be to view direct care positions like skills training and caregiving as careers rather than entry level positions.  If we view direct care as a career, commensurate with a salary that paid a living wage, maybe we’d be valued beyond simply being necessary to maintain staffing ratios with a warm body.  It’s not that our role isn’t appreciated, rather the praise and appreciation rings hollow.  Health care is a hierarchical system to the extreme, we’ve simply got to value the bottom rung employees more than we do currently.  We can do this by acknowledging that it’s not education so much that matters, but aptitude.

However, it’s not just that we pay direct line staff better, we need a voice as well.  Too often floor staff are given clinical directives and treatment goals with little regard to the practicality of what we’re being asked to do and how we manage people (both staff and clients).

The tools we need in the residential setting, such as structure in the form of consistency of basic routines and expectations, are frequently undermined.  It is often said that children respond well to structure, but it also supports us as direct caregivers.  We have exhausting jobs, the unit’s culture needs to be maintained perhaps more so than any treatment modality.  A huge part of the problem is when milieu management is directed by clinical theory without balance or voice given to practical concerns.

Oh, and clinicians don’t always make very good managers of people.