Creating and Supporting Coercion-Free and Violence-Free Treatment Environments

Creating and Supporting Coercion-Free and Violence-Free Treatment Environments The Village Network The Knox County Children’s Resource Center Dave Paxton, LISW-S Regional Director

The Children’s Resource CenterFacility Profile • Community based, open children’s residential center • Partnership between the Knox JFS and the Village Network – 1999 • 20 bed capacity • 4 Transitional Living Beds

The Children’s Resource Center Facility Profile • Co-ed, 10 to 18 years of age • Primary Diagnoses: PTSD, mood disorders, attachment issues. • Majority of clients have significant history of abuse & neglect, are involved with JFS & are on juvenile probation.

The Children’s Resource Center Initiative • Reduction restraint initiative started summer 2004 • 2006: 135 physical restraints. • 2007: 217 physical restraints.

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Existing culture: • Emphasized holding clients accountable • Perpetuated the belief that something was “wrong” with client • Focused on controlling the client (power & control)

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Existing culture: • Staff were rewarded for having a “quiet” shift • Use of restraints was thought of as routine interventions • Perpetuated the belief that restraints were therapeutic

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Existing culture: • Focus was not on the health of our staff, but on the unhealthy ways our client’s behaved • Focused on staff and program needs, not client needs • Compliance was understood to be clinical improvement

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Existing culture: • Retraumatization not part of our vocabulary • High number of injuries to staff, medical leaves and worker compensation claims

The Children’s Resource Center Strategies • Program staff attended a NTAC in 2004 • Original member of learning community

The Children’s Resource Center Strategies Culture Change • Creating the Upside Down Organization • The hope of Transformation Education has nothing to do with fixing children, but rather about healing the organizations that prevent children from overcoming the obstacles they encounter to learn and grow. - Andrew Ross, 2005 The Children’s Guild, Baltimore, Maryland

The Children’s Resource Center Strategies – Culture Change • Assumption 1: There Is No Relationship between How Organizations Are Designed & How the Brain Operates. The culture needs to be designed to promote the connection among the children (clients), among the staff and the children, and among the staff, and do so in a way that fosters meaningful experiences. -Ross, 2005

The Children’s Resource Center Strategies – Culture Change • Assumption #2: The Organization’s culture is Functional & Therefore More Healthy than the Dysfunctional Culture that Created the Maladaptive Social, Behavior & Emotional Problems of the Child. • Many organizations claiming to be child centered are actually staff-centered. This incongruity results in reinforcing the very cultural mindsets of dysfunction, power and control that brought the child into care. -Ross, 2005

The Children’s Resource Center Strategies – Culture Change Assumption #3: The Culture of an Organization Designed to Serve Emotionally Disturbed Children Should Focus on Treatment • It does not account for the fact that the professional staff (Licensed MH pros) spend the least amount of time with the clients. This focus is necessary but not sufficient. The staff needs to focus on teaching values and life skills. Teaching and relationship building take a back seat to efforts to control behavior. -Ross, 2005

The Children’s Resource Center Strategies • Developing a Culture of Recovery • 2005 began process of implementing the tenets and approaches of trauma informed care. • Focus began to switch to the effects of abuse and neglect on not only our clients, but on staff as well.

The Children’s Resource Center Strategies • Change in aggression control training to CPI with more emphasis on de-escalation. Agency wide training. • Restraint reduction became a company wide initiative with the approval of The Village Network’s Board of Directors. • Wording of TVN policies around the use of restraints was changed to reflect emphasis on the need to apply as the last resort.

The Children’s Resource Center Strategies • Implemented “witnessing” in 2004 • Elevated the importance of physical restraints to the level of a major critical incident. • All critical incidents reviewed in staff meetings. • Combination of witnessing, CIR reviews and debriefing resulted in increased oversight, accountability and communication around every critical incident.

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Vocabulary began to include such terms as trauma and recovery, safety, grief, hope & hopelessness, needs, hurt and pain • The idea that a restraint indicates a failure in treatment was introduced • Training includes material from Perry, NCTSN, Briere, ACE’s study, Putman and other sources • Staff are challenged to identify what our clients need in the moment • De-emphasis on minute rules

The Children’s Resource Center Strategies • Developing a Culture of Recovery • In2006 implemented a specific treatment approach for the milieu with emphasis on client’s strengths and teaching. • Provides many tools for child care staff to work with clients. • Six month training process

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Emphasis on implementing proven and best practice models of interventions. Group Therapy Curriculum: • SELF Model (Bloom) • G-TREM (Community Connections) • Aggression Replacement Therapy/Equip Program • Expressive Art Therapy • Getting Ahead for Independent Living • Individual therapy: • TF-CBT & Self (trauma theory, Briere) • Community Safety Group

The Children’s Resource Center Strategies Parallel process Complex interaction between traumatized clients, stressed staff, pressured organizations, and the social and economic environment. Our systems frequently replicate the very experiences that have proven to be so toxic for the people we are supposed to treat. Brian Farragher, LMSW Andrus Children’s Center

The Children’s Resource Center Strategies • Developing a Culture of Recovery • Program has become more inclusive to families • Family visits are not contingent upon client’s “earning” their privileges • Family Day • Increase in family therapy

The Children’s Resource Center Strategies • Debriefing • Debriefing form is filled out within 24 hours of restraint incident. • Focuses on: -Was restraint necessary? (eminent risk of harm) -Could have the restraint been prevented? -What did the child need at the time?

The Children’s Resource Center Strategies • Assessment Tools • Behavioral assessment upon admission including a restraint risk assessment. • Trauma Symptom Checklist for Children (Briere) • Dissociative Scales (Putman)

The Children’s Resource Center Strategies • Consumer Roles • Community Safety Group – weekly group that allows residents to express concerns and safety of the program/facility is discussed. • Residents will have in-put into annual staff performance evaluations (current project).

The Children’s Resource Center Strategies – Physical Environment Time-out room Storage closet

The Children’s Resource Center Strategies – Physical Environment

The Children’s Resource Center Results • Reduction restraint initiative started summer 2004 • 2006: 135 physical restraints. • 2007: 217 physical restraints. • 2008: 14 physical restraints: 94% reduction

The Village Network - Children’s Resource Center Number of Physical Restraints by year & month: 2005 - 2008

Creating and Supporting Coercion-Free and Violence-Free Treatment Environments