|
When Programs Have Problems…
Explores the theory and practice of
trauma informed and relationship based treatment for children and
adolescents, using the Restorative Approach. ©2006 The Restorative
Approach is a servicemark of the Klingberg Family Centers, Inc.
Sunday, November 26, 2006
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.
// posted by Patricia Wilcox, LCSW
|
