Residential Services in Transition:

Meeting the Challenge

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The field of residential group care has experienced many challenges over the past 10 years. This has intensified recently, as news articles highlight youth seriously injured or killed in residential-type facilities, such as boot camps. While many residential treatment programs are licensed and accredited through one of the major accrediting bodies, controversy surrounding the quality of services continues to make headlines. Some youth and families are asking for more community-based services, which would allow them to access early intervention services. The focus on transforming the mental health and child welfare systems has created additional pressure for residential providers to transform, compounded with a recession that is forcing many providers to do business differently.

As systems shift to have more community-based services and shorter lengths of stay, residential treatment facilities-- in particular those that serve the child welfare system--have seen a corresponding increase in the level of severity and intensity of the mental, emotional, and behavioral problems of youth entering these facilities. This has increased the challenges as providers try to shift their programs to respond while demonstrating quality service delivery and improved outcomes for the children and families served. "The fact is, there really has not been enough research done to clarify when residential is appropriate, [and] which treatment models and approaches work, for which population of youth and for how long," says Fred Chaffee, CEO of Arizona's Children Association and Chair of CWLA's Mental Health Advisory Board. A few efforts, however, are doing exactly that.

A National Initiative

The national Building Bridges Initiative (BBI), under the skillful leadership of Gary Blau, Chief of the Child, Adolescent, and Family Branch at the Center for Mental Health Services, was created in direct response to the historical tensions between residential and community-based providers. The initiative is guided by a steering committee with membership from national residential and community organizations, families, and youth. The Joint Resolution developed in 2005 as part of this initiative specifically articulates the value of residential treatment within a broader array of services and identifies mutually agreed upon values and principles for service delivery. More than 20 national organizations have officially endorsed this Joint Resolution.

"In addition to the Joint Resolution, we have developed numerous work products to support quality services for youth and families. For example, we have developed a self-assessment tool for providers to gauge their readiness to implement the BBI approach, and we have a Family Tip Sheet that can help in choosing the right residential provider," says Blau. He reports that there are now a cadre of leaders in the field, both public and private, that have been testing these tools and providing feedback and technical assistance to others as they begin their journey of transformation.

Provider agencies such as CWLA member EMQ Families First in Campbell, California, have implemented aspects of the BBI. "About eight years ago, we embarked on an initiative to redesign our services to reduce our use of restraint and seclusion," says Lisa Davis, Clinical Director at the agency. "We eventually realized it was not enough and that we needed to do more. The BBI has helped us focus our efforts. Along with implementing many evidence-based practices such as Trauma Focused Cognitive Behavioral Therapy (TF-CBT) and Positive Behavioral Support (PBS), we have fully embraced shifting from child-centered to family-centered care, incorporating family focused approaches in our work." She reports that all EMQ Families First services are guided by this approach. "The family drives what goals they will work on. Each family has a family partner that helps them navigate the system," Davis says.

In EMQ Families First's model, services are tailored to the family and community and much of the service delivery takes place in the home. "The family is supported to effectively care for their children and the children basically just visit the residential program, versus the other way around," Davis says. The agency has taken to heart the Joint Resolution principle of "families as equal partners," as evidenced by their recent merger with the family-run organization their name reflects.

Work at the Provider Level

Many residential providers have responded to the pressure to transform--whether by choice or by force. Some have been required to close or greatly reduce their number of available beds. Others are adjusting their service delivery to have more community-based care or greater linkages to the community-based service delivery system. "Given the lack of research in residential treatment, many providers have committed to a continuous learning environment and to improving their quality of services through collecting outcomes data, researching and evaluating what they are doing, and creating Continuous Quality Improvement [CQI] Systems," says Thomas E. Rembiesa, President and CEO of Ruth Dykeman Children's Center in Seattle and co-chair of CWLA's Residential Advisory Committee. "Others are implementing evidence-informed and evidence-based programs and practices. Many have been implementing all of these changes."

Some CWLA member agencies have been working with researchers and practice model developers to test out evidence-informed and evidence-based approaches that can lead to helpful information for the field. Jewish Board of Family and Children's Services (JBFCS) was the first agency to help adapt the Sanctuary(R) model from a hospital model of adult trauma treatment to one for children and adolescents in a esidential setting. "The convergence of external pressures--especially what was going on in child welfare in the 1990s--and the new information related to working with traumatized youth led to the reexamination of therapeutic modalities in residential care at JBFCS," says Lenny Rodriquez, Deputy Executive Director at the agency. From 1996 to 2001, three of its residential treatment facilities worked under the skillful leadership of Dr. Sandra Bloom to adapt the model.

Through this hands-on adaptation process, JBFCS has not only transformed its therapeutic program but also provided the field with important information on a method for creating an effective trauma-informed and trauma-sensitive therapeutic environment for children and youth in a residential setting. This effort provided helpful information regarding the challenges for adapting, implementing, and training, which further refined the model. This evidence-based model is now being more rigorously tested in other residential facilities for children and youth.

Waterford Country School in Connecticut recently began implementing Cornell University's new Children and Residential Experiences (CARE) Program. The CARE curriculum will be published by CWLA soon. "CARE is a best practice model that creates conditions for change for youth in congregate care," explains David Moorehead, Executive Director at Waterford. Staff will be working with the developers to document outcomes of the implementation and effectiveness of this approach within the residential facility setting. Michael Nunno, Principal Investigator of the Residential Child Care Project at Cornell University, says CARE is "a multi-component strategy" involving specific training for agency staff to guide their interactions with children using six evidence-based principles, ongoing consultation, and the development of a climate that can sustain these practices.

"In my almost 30 years at Waterford I have been waiting for a treatment model that is all-inclusive, and CARE provides this," says William Martin, Assistant Executive at Waterford. "It challenges the fundamental belief of child care practice at every level of the organization and pulls together several promising practice initiatives we had already had into a strategy that ties together these approaches." He is encouraged by how quickly the staff has embraced the model. "The climate at Waterford has shifted to being more responsive to the individual needs of clients and families," he says.

The Children's Home Society of Washington in Seattle has taken a different approach to changing the delivery of residential services. Guided by the strong desire to ensure children and youth are not inadvertently retraumatized, the agency has made significant changes in its Cobb Center residential program for boys age 6 to 15. Jason Gortney, the program's manager, says that of the youth served in this program, 99.9% have traumatic early childhood experiences, an average of three DSM-IV AXIS 1 diagnoses, and seven failed placements. After reviewing research on the impact of trauma, as well as emerging evidence-informed and evidence-based programs and practices for children and families, the agency took aspects of different models and implemented them into its practice. "Over the past few years there has been a concerted effort to transform the way we look at the behaviors youth present. We have begun using a trauma lens, recognizing the need to address the effects of maltreatment," says Gortney.

The Cobb Center uses a number of trauma assessments, including the UCLA PTSD Reaction Index Trauma Screen and the Child PTSD Symptom Scale. Therapists use the evidence based TF-CBT with the children. In fact, all staff receive training in the fundamentals of this model. In their day-to-day interactions, staff work with children and youth on the same skills the therapist is focusing on. This way, children and youth develop and apply the skills in their everyday lives.

The program no longer has a point-and-level system of discipline; it now uses the Collaborative Problem Solving (CPS) approach developed by Dr. Ross Greene, a Harvard psychologist. This is an evidence-based proven approach to understanding and helping children and youth with challenging behaviors. This approach recognizes that children with emotional, social, and behavioral problems have developmental delays and lack the cognitive skills to respond appropriately. "We have been able to go from a punishment-based approach with rigid rules to one that recognizes the early warning signs for problem behaviors or when youth have been triggered, and help them develop the skills to cope," Gortney says.

The Cobb Center provides families with psychoeducational programming and intensive family therapy. As with EMQ Families First, there is a strong in-home component, with workers providing support and focusing on skill building. As the center evolves the model, staff hope to strengthen the family component further to be more family-driven. They are already beginning to see the benefits of these changes, including a significant decrease in the use of restraints and seclusions. "We will be studying the results--learning and refining as we go--to make sure we are getting good outcomes for the children and families we serve," Gortney says.

The Hillsborough County Department of Children Services in Florida also looked to the research and emerging evidence-based practices and approaches when developing its short-term trauma-informed residential program. The Family Treatment Program was created to provide services for families whose functioning is severely impaired and who have significant challenges with youth in the home, community, and school. Residents in this program stay an average of six to nine months; youth live at the residential program during the week and go home on weekends.

"It is designed for the whole family to make a commitment and work on themselves," says Barry Drew, the director of the program. "The intent is to provide a break for the families and help the parents and youth develop the skills they need to have healthy relationships and be successful in their lives. Many of the services take place in the family home." Parents and families are helped to address their own personal happiness and suffering. The program incorporates many evidence-based practices, such as TF-CBT, which is used with both youth and their parents. Most family members in the program have experienced some type of trauma that needs to be addressed. The family also receives intensive family therapy and parents are provided with other supports and services as needed. The Incredible Years program is used when there are younger children in the family with challenging behaviors. This evidence-based program has proven effective in reducing younger children's aggression and behavior problems while increasing their social competencies.

According to Drew, the program is committed to using nonabusive psychological and physical interventions based on the NAPPI International model, resulting in no use of seclusion or restraints. "We conduct a functional behavioral analysis and focus on building on the strengths of the youth and their interests to help them learn how to deal with issues and feel better about themselves. Through this, we help youth master the world around them in effective ways. Staff use every moment and activity as an opportunity to help youth develop skills," he says. Staff are taught to assess the self-concept of youth, in which they always ask these questions: Did what took place help the youth to feel better about themselves? Did they develop a new skill? New confidence? Daily report cards are kept and reviewed to help the staff get better at using every interaction or activity as an opportunity to help youth succeed.

A unique feature of the Family Treatment Program is its focus on improving reading scores. Most youth have poor reading scores, which in turn impacts their self-concept and ability to succeed. Integral to this goal is the program's use of a therapeutic activity protocol based on the needs, strengths, activities, and interests of each youth. The protocol is designed based on the youth's emotional/therapeutic needs and uses activities they are interested in. For example, when a youth is planning an outing, he or she might read about it online before going. Or, a youth might read about different foods and the countries where they originate when he or she goes to a restaurant. The youth then talk about what they learned when they return.

Drew reports they see continued improvements in the families and youth involved in the program, including family functioning, parental relationships, interaction between the parents and youth, marital stability, job stability, and financial stability. The Achenbach scores for the youth reflect the improvements and schools report improvements in behavior and academics--particularly reading. A Quality Assurance staff person gathers data, including satisfaction surveys, and helps continuously modify the program based on data and feedback.

Spurwink Services, which provides behavioral health, educational, and residential services throughout Maine, has actually developed an Outcome Measurement & Research Department. "To help us respond to increased state pressure to report outcomes and have a better understanding of the progress and effectiveness of our treatment for youth, we established this department, allowing focused resources to study clients served," says Linda Butler, Director of Research and Special Projects. "A departmental goal is to systematize data collection and use the data to provide Performance Quality Improvement (PQI) to administration and clinical staff." The agency created a computer database to track outcomes data; staff across the decentralized agency use this database. "We use the results from the outcome research to improve existing services and plan for new programs," Butler says.

The vast majority of youth at Spurwink Services have been traumatized and have a variety of complex, severe psychiatric, cognitive, and behavioral challenges. In order to serve this population, the agency has adopted many evidenced-based practices, such as TF-CBT, standard CBT, motivational interviewing, functional family therapy, and CPS. "Spurwink embraces an overarching 'relational paradigm' derived from basic psychodynamic and interpersonal therapy traditions," Butler explains. "Our model relies heavily on the centrality and importance of the relationship between the youth and his or her team members and is based on caring, respect, and empowerment."

According to Butler, the establishment of her department has increased the cultural importance across the agency of systematically tracking outcomes. This has provided a heightened level of opportunity to interact and learn from other professionals in the field, both nationally and internationally. It has also highlighted the importance for clinical staff to have an atmosphere of questioning and learning, which enhances treatment and outcomes for youth. "We engage in formal research studies to further the agency's understanding of clients served and inform the professional field. Our current studies include a follow-up investigation of clients' health and well-being after residential treatment at 3, 6, 12, and 18 months postdischarge, and a qualitative focus group study of former residential clients and their parents," says Butler.

The organizations and initiatives mentioned in this article are representative of the variety of creative and innovative efforts taking place to improve the quality of the services being provided. They share a common commitment to continuous quality improvement and using the research that is currently available, while documenting to inform the field about what is working, all with the intent of improving the lives of children and families. This is the first in a series highlighting what is being done at the national, state, county, and community provider level to transform residential programs to ensure improved outcomes for children and families. The second in the series will focus on effective approaches in preventing the use of restraint and seclusion.

The writers are interested in hearing from public and private agencies regarding what they are doing to document practice-based evidence and implement evidence-informed and evidence-based best practices for improved outcomes for children, youth, and families served. Contact them at jcollins@cwla.org or lrichmond@cwla.org.

To comment on this article, e-mail voice@cwla.org.

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