Photo: Emelie Asplund
Restrictive therapeutic facilities — inpatient psychiatry units, residential facilities, group homes and juvenile detention facilities — serve the most challenging youth in society. Before admission, these children and adolescents have often been on the receiving end of countless detentions, suspensions, expulsions, restraints, seclusions and corporal punishment. Many have significant trauma histories.
Often these youth began the long road toward disenfranchisement, marginalization and alienation in early childhood, and many have lost faith that the adults who are supposed to be helping them actually will. The human element aside, these are also the most expensive kids in our society. Governments spend hundreds of thousands of dollars on each of these kids during their childhood and adolescent years.
And yet, many restrictive therapeutic facilities still rely quite heavily on the very same behavior modification strategies that may already have proved ineffective before the youth was admitted. This may explain why such facilities still have high rates of restraints, seclusions, staff and resident injuries, and recidivism. Perpetuating ineffective treatment serves no one well.
The model of care I originated and described in my books “The Explosive Child” and “Lost at School” — called Collaborative & Proactive Solutions (CPS) — has been implemented with varying degrees of fidelity in countless restrictive therapeutic facilities. The model typically reduces the use of restraint and seclusion dramatically. Perhaps even more important, in the juvenile detention system of the state of Maine it dramatically reduced rates of resident and staff injuries and recidivism, from approximately 75 percent to approximately 15 percent. The model is now being implemented in adult restrictive therapeutic facilities with similar effects.
There are a variety of components to the CPS model. Here are some of the most important:
A psychiatric diagnosis is the least informative piece of information about a resident. Diagnoses don’t actually provide much information about why a resident is exhibiting challenging behavior; they just tell us what challenging behaviors the kid is exhibiting. In the CPS model, challenging behaviors are viewed merely as the means by which a resident is communicating that he or she is having difficulty meeting certain expectations. Whether a kid is hitting, spitting, biting, kicking, throwing things, screaming, swearing, destroying property or worse, the behaviors are communicating the same thing: I’m stuck … there are expectations I’m having difficulty meeting.
The research that has accumulated over the past 40 to 50 years tells us that behaviorally challenging kids are lacking important cognitive skills, especially those related to flexibility/adaptability, frustration tolerance and problem-solving. That’s why these kids explode or exhibit challenging behavior when certain situations are demanding those skills. The research does not tell us that behaviorally challenging kids are poorly motivated. Thus, motivational strategies may not be what they need from their caregivers.
Like all of us, behaviorally challenging kids exhibit challenging behaviors when the expectations being placed upon them outstrip their skills. Because they’re lacking skills, the clash between expectations and skills occurs more often in behaviorally challenging kids, and their reaction tends to be more extreme. That explains why behaviorally challenging kids aren’t always challenging: the clash between expectations and skills isn’t constant, it’s situational. It’s limited to certain conditions and expectations.
One of the most important things staff in therapeutic facilities can do for a behaviorally challenging kid is to figure out what skills he or she is lacking and what expectations he or she is having difficulty meeting (in the CPS model, those unmet expectations are referred to as unsolved problems). This is accomplished by using a screening instrument called the Assessment of Lagging Skills and Unsolved Problems (ALSUP). You can find the instrument on the website of my nonprofit Lives in the Balance. And just like all the rest of the vast array of resources you’ll find on that website, it’s free.
There’s something else you’ll find there: lots of information on how to solve those problems with the kid. While many caregivers try to solve those problems unilaterally, through the imposition of solutions — that’s called Plan A in the CPS model — you’ll be a lot more successful (and provide a resident with better preparation for the real world) if you solve those problems collaboratively instead (that’s called Plan B). When you solve problems collaboratively with a kid, you become partners — teammates — rather than enemies or adversaries.
Plan B consists of three steps: the Empathy step, the Define Adult Concerns step and the Invitation step. The primary goal of the Empathy step is to gather information from the resident about his or her concern, perspective or point of view on a given unsolved problem. This is a very important part of the problem-solving process, especially since caregivers often assume that they already know the factors that are interfering with a resident meeting a given expectation. It is in this step where the resident’s voice is heard and where he or she learns to identify and articulate his or her concerns. It’s also where adults learn to listen.
The Define Adult Concerns step is where caregivers enter their concerns about a given unsolved problem. It is in this step that the caregivers’ concerns are heard, and where kids learn to listen and taken another person’s perspective into account. The Invitation step is where resident and caregiver collaborate on a solution that will address the concerns of both parties. This is where both caregiver and resident learn to generate alternative solutions and resolve disagreements without conflict.
If you’re going to solve problems collaboratively, then you’ll also want to solve them proactively. The heat of the moment is bad timing for problem-solving. In fact, the failure to solve problems proactively is why crisis management strategies are so commonly utilized in facilities. But how can you solve problems proactively when a resident’s challenging episodes are so unpredictable? Well, they’re actually not as unpredictable as they might seem. Once staff use the ALSUP to identify those unsolved problems, they become predictable and can be solved proactively.
Prioritizing is crucial. Many residents have large numbers of unsolved problems that have accumulated over many years. Solving all those problems can feel daunting and overwhelming. Prioritizing makes it more manageable. One of the biggest reasons the unsolved problems of behaviorally challenging kids remain unsolved is that their caregivers try solving them all at once.
Once staff creates a comprehensive list of unsolved problems — all the expectations the resident is having difficulty reliably meeting — two or three high-priority unsolved problems are selected. The rest are being set aside for now (that’s called Plan C). Which unsolved problems should be prioritized first? Any that are causing safety issues. If there are none of those, then you’ll want to prioritize those that are causing challenging episodes most frequently or those that are having the greatest negative impact on the resident’s life or the lives of others.
One of the nice things about seeing a resident’s difficulties through the prism of lagging skills and unsolved problems is that it permits staff to stop referring to the resident child in ways that are inaccurate and counterproductive: attention-seeking, manipulative, coercive, unmotivated, limit-testing, button-pushing, sociopathic, psychopathic and so forth.
Focusing on lagging skills and unsolved problems has another benefit: It helps staff focus on the things they can actually do something about. In too many facilities, staff are focused on environmental/historical factors that they believe “explain” how a resident came to be behaviorally challenging: bad neighborhoods, trauma histories, prenatal exposure to substances, poverty, dysfunctional families, neglectful parents. Often, these are factors about which staff can do very little. Better to view those environmental/historical factors as delaying the development of crucial skills and making it difficult for the resident to meet certain expectations. Lagging skills and unmet expectations are factors staff can do something about.
These principles represent a dramatic shift for many facilities. It’s a shift that is frequently made slowly, over a period of several years. It requires patience, perseverance, teamwork, organization and leadership. The other option is to have things remain as they are.
There are many common misperceptions about the CPS model. One is that it involves removing all expectations. It’s not possible to run a facility without expectations. It’s how staff handle unmet expectations that determines whether those expectations are ultimately met or instead result in behaviors that cause staff to feel unsafe. Another misperception is that the CPS model reduces adult authority. In reality, it helps adults use their authority in ways that are far more productive.
Ross W. Greene, Ph.D., was on the faculty at Harvard Medical School for 20-plus years, and is now founding director of the nonprofit Lives in the Balance, on the adjunct faculty at Virginia Tech and the University of Technology in Sydney, Australia, and author of the books “The Explosive Child,” “Lost at School,” “Lost & Found” and “Raising Human Beings.”
