To Be the Best Healing Environment Caroline McGrath Executive Director UMass Adolescent Treatment Programs Clinical Instructor UMass Medical School

Brief Historical Overview National S/R Reduction Initiative 1988 Hartford Courant Series 1999 GAO Report ( Congress) NASMHPD MD S/R Report 2002/03 NASMHPD Training Curriculum created and training begins 2003 New Freedom Commission Report (Transformation) 2004 SAMHSA funded sig grants begin

Major Change Constructs (core beliefs that provide a foundation) in preventing conflict, violence and S/R use) Leadership Principles for effective change The Public Health Prevention Approach Use of Recovery/Resiliency Principles Valuing Consumer/Families/Staff Trauma Knowledge appreciated Staying true to CQI Principles

Why Am I HERE ?

Some of the Myths We have faced…. “Our unit has the most challenging kids in the state, we can not reduce our use of restraint.” “Our staff are already getting hurt, we will not be able to find people to work” “We have to provide these external controls, because the kids do not have internal control.” “There is going to be chaos.” “The kids will not learn how to change their behavior without these limits.”

Elimination of a Restraint is a Necessity Most of the children we are serving have a history of trauma. When a child is admitted to a program, it is one of the most poignant times in their life. Our first responsibility is to cause no additional harm to an already vulnerable child. Our use of restraint and seclusion causes additional trauma to both the kids and our staff. Our responsibility of providing a healing environment is incompatible with violence happening in the program.

A whole new lens… Many of the initial changes in our thinking, and culture were about seeing the kids differently. We read and appreciated the work of Ross Greene, PhD who says, “Children do well if they can.“ Training in Collaborative Problem Solving helped us to appreciate that kids want to do well, and if they are having challenging behaviors they are not doing it on purpose. We began to appreciate that their “maladaptive behaviors” are their best attempts at coping with their difficulties in self-regulation and life’s daily challenges.

A Trauma –Informed Lens We adopted the concept of “universal precautions.” This helps us to better appreciate the prevalence and pervasiveness of trauma in the kids we work with. We have a responsibility to make sure our practices and policies are trauma-sensitive. Seeing the kids’ behaviors through a trauma-informed lens deepened our empathy for the adversity they faced, and helped us to understand that their “trauma logic” was not so crazy. have

Our thinking and practices have been changing… As we gained increasing knowledge about the far reaching effects of trauma we began to look at everything about our programs. The culture of the unit began to shift; the culture is expressed by the norms, language, behavior and customs. Culture is best reflected in “the way we do things around here.” We started questioning our vision, mission and rules. We started asking each other “why do we do it that way? Is that what is best for a child who has a history of trauma?”

The needs of all children… Kids need to move, get outside and run and swing. All kids need to know they are important to somebody, they need to know that staff will give them the benefit of the doubt, and will notice what’s great about them. Promote the innate resilience in children. Post the work on resilience by Edith Grotberg. “I am, I can, and I have.” What are their assets and ... Strengths in these areas?

The “one-down” approach A significant culture change in our programs has been about changing our language in both verbal conversation and written documentation. We use “person-first” language that is strength-based. We have also done extensive training in the philosophy and stance of taking a “one down” approach. It is youth-guided and family centered; it values the expertise of the child and family in being in the drivers seat.

Embedding the NTAC Strategies (meet criteria to be an EBP) Leadership towards organizational change Use of data to inform care Workforce development Restraint and Seclusion Prevention Tools Use of Consumer Roles Rigorous Debriefing Leadership builds consensus about values, vision, and mission and brings together a guiding coalition to make a strategic plan. Leadership provides pre-and post witnessing of the use of R & S 24\7. Leadership appreciates the facets involved in changing a culture to improve the care and treatment environment. These facets include the norm, language, and customs. It is “ the way things get done around here.” Data is elevated and reviewed daily, hung in all areas for stakeholder review also. How we changed our hiring, orientation, performance eval., and promotional decisions.

Leadership Towards Organizational Change Leadership builds consensus on the values, vision, and mission, and creates the roadmap or strategic plan to get there. A vision people can rally around. Leadership elevates the necessity of eliminating the use of R & S and provides 24/7 witnessing of all restraint events. Leadership shapes the culture of the organization; the leadership demonstrates the values and priorities by their actions including how they solve problems.

Using Data to Inform Care We increased the kind of data collected and reviewed and posted the data more frequently. We looked for trends and patterns, and this helps us to see where we need to focus our training. The data informed us about which kids we were restraining, what time of day we were using more restraint use, and which RN’s and MD’s were ordering the most restraint. If you see a pattern of the restraints going up, look at what is going on at the system level. Using Data to Inform Care

The FISH Philosophy A framework for organizational change We recently had a FISH Kick off to help us to elevate what is important by providing employee recognition for those behaviors and actions that support our vision, mission and goals. Four elements of the FISH Philosophy PLAY BE THERE MAKE THEIR DAY CHOOSE YOUR ATTITUDE

Workforce Development Our recruiting, hiring, job descriptions, orientation, performance evaluation, transfer and promotional decisions have been modified to reflect our clear sense of our vision and values. Training is provided in the following areas: Strength-based care, the one-down approach, The effects of trauma and tic, sensory integration, Collaborative Problem Solving, treating self-injury and the FISH philosophy. Culure is an Academic environment, devoping expertise , but always more to learn

Restraint and Seclusion Prevention tools Collaborate with children and families to create and practice highly individualized coping plans. Emphasis is placed on identifying and practicing skills and self-soothing activities that kids can easily use when they are discharged. Trauma Assessment and Universal Precautions. Increase self awareness, individualized sensory needs and the tools that are helpful.

Use of Consumer Roles Elevating the expertise of children and families with lived experience Including and integrating the voice of people ”who have been there” Youth voice at all levels of our unit, programs and at a state level. In addition we are hiring a family partner. We hired two young adult peer mentors for our residential units. They work along the staff and faculty. They demonstrate the resilience of the people we serve.

Rigorous Debriefing It is a tertiary prevention tool that cannot act in isolation. It demonstrates a synthesis of the other five core strategies. Witnessing by administration, using data to determine patterns needing change, involving the workforce in correcting experiences, updating the tools used to reduce restraint and seclusion, ensuring the process is child–centered The use of apology has become an important ritual at the start of every restraint debreifing.

Saying We’re Sorry We have had a dramatic culture change in how we see and complete the debriefing process. The team asks the youth if it is a good time to meet and who they would like to have at the meeting. Families are also encouraged to participate. The youth is given an opportunity to explain what happened through their eyes and to describe where the points of conflict occurred. The process of the debriefing meeting is an important opportunity for restoring a positive relationship.

Closing Remarks… “It is not what you look at that matters, it is what you see. “ Henry David Thoreau