How do programs create a safe student culture?

Teens entering residential care are often impulsive, angry, guarded and anxious. Of course when they arrive they are now living among other teens with similar feelings and at varying stages of development. Verbalizing their fears in healthy ways is often beyond their ability for at least a few weeks. Any questions regarding their behaviors early on in treatment seems to only intensify feelings of guilt and shame and initiate defensiveness. It often feels like any attempts at therapeutic interventions at this stage will be inadequate and even counterproductive. Earlier on, teens tend to be highly resistant to developing relationships with staff and peers and are hyper vigilant in blocking any type of approach.

The only way to break through the tough veneer is to demonstrate a deep level of integrity. If properly demonstrated, integrity is able to exhibit reliability and honesty. The very presence of staff creates an impression that the main focus is on helping the teen, not on benefitting the adults. The culture of the entire program must show this posture of integrity in order for the teen to begin the process of lowering his or her guard.

Only a positive environment will give opportunity for change as well as reduce the risks associated with teen care during the journey. Of course, any program that is able to bring lasting solutions to troubled teens’ problems is also exposed to the potential of incidents. A positive culture will reduce risk and, in turn, increase the positive outcomes for youth.

In order to create a positive culture, there are many known factors that influence success. Here are a few of the most critical elements in any top-notch therapeutic program:

Structure

In order for students to gain new directions in their lives, the program must provide structure with constructive guidelines. Teens often feel out of control and anxiety only builds as fears of the unknown remain. A structured and consistent program allows parents and teens to have realistic expectations. But the program also needs to be flexible – too much structure can be as detrimental as too little. Choices must never be negated by routine and order, for it is through choices that learning may occur. Even though most students arrive reluctant and resistant to counseling and the prospect of change, they must sense that the program is capable of helping them change. To be motivated to change, one must at least believe personal change is possible within the environment.

Staff development

Staff skill development plays an important role in any quality program. Barbara F. Okun noted in Effective Helping (1982) that there are five characteristics that caregivers on any level should possess: self-awareness, honesty, congruence, ability to communicate, and the knowledge of how to establish rapport and build a positive relationship. These are skills that staff in every position of the treatment facility should possess in order to establish a deep connection with teens. Effective nonverbal and verbal communication is the path to establishing rapport. Seeing the world from the student’s point of view might only be the first step, but it is critical. This understanding must be communicated; then trust that develops through feeling safe can be established. Staff and youth alike must have a sense of belonging, value, being treated with respect, dignity and acceptance. There must be freedom to make mistakes, to forget, and to ask for help.

Relationship building

Relationship-building skills in residential treatment programs most often start with managing conflict. Conflict is inevitable in therapeutic programs that work with struggling teens. Well-trained staff is able to avoid power struggles and turn conflict into a meaningful growth experiences. Quality staff knows how to stop, listen, identify the problem and allow the teen to develop solutions. They actually hunt for win-win solutions by involving the youth in decisions and exploring some choices and consequences.

We expect our staff to be firm but friendly, definitely not aggressive and most importantly, to separate the behavior from the youth. Staff skills must include the ability to control negative emotions (especially their own) and avoid escalating the situation whenever possible.

Effective communication is not only a method of disclosure, but also a path to discovery. Effective listening will broaden a youth’s view of himself and the world around him. This type of really engaged ‘active’ listening requires strict attention and the ability to be objective in situations that will often evoke strong opinions and judgment. Listening at this level demonstrates a true willingness to be part of a meaningful exchange and instead of just confront. According to Bowman (et al., 1998) good active listening is being able to encourage, clarify, restate, reflect, summarize and validate.

Summary

Good quality therapeutic programs understand how to create a positive culture. In spite of working with resistant students, Shelterwood has always found a way to help their students lower their walls and open themselves up to their great potential. The teens we get to work with have tremendous gifts and abilities that often lay dormant under the heavy weight of self-doubt and fear. Helping our teens uncover their true identity is a truly rewarding experience for us all.

What Does a Good Program Look Like?

Matching of Facility Resources and Family Needs
Once the difficult decision is made that residential treatment will be required parents face the formidable task of selecting among the myriad programs that advertise nationwide.

Like therapists, residential programs vary widely in their goals, their theoretical orientation and treatment paradigms, and the specific features of their treatment settings. Parents may gravitate toward the relative intimacy of four- to six-bed facilities housed within single-family residences or they may lean toward larger institutional facilities housing dozens of students on larger more complete campuses.

Residential treatment centers also vary widely in their geographic distribution, cost, emphasis on amenities, emphasis on group cohesiveness within the milieu, and length of stay. The expected or typical length of stay also varies widely among residential treatment programs. Many programs recommend minimum lengths of stay of between one and three months and some have lengths of stay that range from six months to two years or more.

We strongly encourage parents to seek out markers of quality and to ask many questions before committing to a particular program. There are no standardized or nationwide ratings of residential programs, and the process of evaluating programs is complicated by the fact that many facilities compete for the same pool of clients. Generally speaking, high-quality residential treatment programs will have in common the following characteristics:

Accreditation and/or licensure: High-quality residential facilities tend to subject themselves to scrutiny and oversight by state licensing authorities or other entities providing accreditation for healthcare organizations. Such licensing and accrediting authorities tend to require strict standards for evidence-based care, documentation, medication storage and handling, and other key aspects of residential care.

Fully credentialed staff: Practitioners who work in residential facilities must be sensitive not only to the dynamics of each individual client but also to group dynamics, the dynamics of conflicts between staff and clients and, perhaps most importantly, the often-subtle indications that a client may be struggling and in need of more intensive monitoring or even acute hospitalization. Less qualified programs will not only fail to recognize their inability to help the client but may be reluctant to release the teen to other levels of care due to the loss of financial stability. Be very wary of programs that are unwilling to refer clients to other programs and require long-term financial commitments.

High staffing ratio’s: Residential facilities with high staffing ratio’s respond well to the fluctuating levels of anxiety within the treatment milieu. Effective treatment programs have the ability provide more intensive monitoring (e.g., on a schedule of wellness checks every 30 minutes, every 15 minutes, or even continuous one-to-one observation) without disrupting the campus culture. Quality staff coverage not only protects the individual client but also helps ensure that the affective environment of the treatment milieu can be modulated and other clients can continue on safely and uninterrupted.

Ready access to urgent and emergency care facilities: Accidents happen and so do intentional acts of self-harm. Residential facilities that have working relationships with local hospitals and urgent care facilities are well positioned to transition clients in crisis to a higher level of care with a minimum of disruption to the milieu.

Actively participating in outcome studies:  The programs of highest quality will want to use scientifically based assessment tools to understand what aspects of their treatment are effective for various presenting problems.  Building an evidence based program is not easy and demonstrates a commitment to client feedback and growth.  Shelterwood is currently participating in a nation wide study that is sponsored by the National Association of Schools and Programs (NATSAP) and are in the process of receiving an endorsement for being an Evidence Based Program.

An aftercare strategy: Excellent programs begin planning for aftercare soon after admission, although in some cases this will be delayed by the need for diagnostic clarification. Outpatient therapists should always be included in the aftercare-planning process, and usually this inclusion can be accomplished by phone or e-mail without the need for therapists to attend meetings in person. According to research a small minority of clients elect to remain in contact with the therapists who treated them during their residential stay, but most patients do not. At Shelterwood, we are very proud of our life-long connection with former clients. Most students remain connected through social media and seek out support years after their stay with us.