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CLINICAL CLUSTER A NEW TOOL TO ENHANCE STAFF COMPETENCIES

By Aaron Jenkins,2014-08-12 19:05
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CLINICAL CLUSTER A NEW TOOL TO ENHANCE STAFF COMPETENCIES ...

    Presented: AACRC Conference

     October 21, 2005

     Pasadena, California

    CLINICAL CLUSTER: A NEW TOOL TO ENHANCE STAFF

    COMPETENCIES, TREATMENT AND OUTCOMES

    Robert J. Marx, LISW

     “By and large, when a young person, for whatever reason, requires a period of out-of-home care or treatment…the families feel defeated and demoralized, and the

    children or adolescents feel overwhelmed and as if their lives are slipping further away from their own control” (Durrant, 1993). All too often, the cultures of many residential programs reflect staff members at various levels of feeling defeated, demoralized and out-of-control. This isomorphic relationship between the culture of the program and the problems of the youth and family reflect both of these systems being stuck in unsuccessful attempts to solve problems and unable to see, let a lone use, alternative solutions that are available to them (Watslawick, Weakland, and Fisch).

     A brief, solution-oriented approach (De Shazer, 1988, 1991) places emphasis on what clients are doing right versus what they are doing wrong. This approach shifts the treatment focus from one of pathology and deviance to one of strengths and “possibility

    therapy” (O’Hanlon, 1993). Most family therapists understand the concept of reframes: changing the meaning of behavior by placing it in a different framework (Watzlawick, et al). These systemic approaches are based upon the basic assumption that behavior has an intent and purpose. In addition, the purpose of the behavior has a benevolent intent; that is, the behavior is an unsuccessful attempt to be helpful to someone.

     Such an approach shifts one’s thinking from behavior control and correcting

    pathology to increasing the client’s understanding of the intent of his behavior and building on her strengths and capabilities. This requires that the staff members of a

    residential treatment program must first be able to “see” the benevolent intent, strengths and capabilities, and alternative solutions in clients who are generally defined in pejorative terms: disrespectful, deviant, homicidal, suicidal, self-defeating, addicted, manipulative, and out-of-control.

     The Rosemont Center in Columbus, Ohio operates a crisis, shelter care program for female adolescents who require an immediate residential placement during a crisis event. The “typical” youth is a 14 year-old, African American female who has been in

    six previous out-of home placements, having been removed from her family-of-origin at age five due to abuse or neglect. The referral and treatment systems describe them as youth who:

    ; Know the “system”

    ; Are astute at predicting system consequences

    ; Have no fear of the Juvenile Court system

    ; Have given up on the system caring for them

    ; Are hopeless

    ; Have no family involvement, family is unknown, or family is not

    available due to incarceration, chronic mental health/addictive issues,

    or are deceased

    ; Have multiple failed placements

    ; Most recent placement was terminated due to unsuccessful discharge,

    truancy, or unmanageable behaviors.

    Regardless of the model of a residential treatment program, the staff members must “live the program” in a manner consistent with the expectations the staff members have for the youth they serve. Increasing their understanding of emotional and behavioral problems by increasing the emphasis on DSM categories would increase their ability to “talk” the professional jargon. However, a DSM emphasis would also

    encourage the focus on pathology and imply that there is a “sameness” about those clients

    who have the same diagnosis. The DSM also does not provide treatment reframes to help the youth begin to see themselves in a different way.

    The systemic concept of equifinality suggests that each family system is unique, that the same origin may lead to different outcomes, and the same outcomes may result from different origins. So the dilemma becomes one of how to categorize youth in a way that recognizes the uniqueness of each youth. The narrative clinical clusters establish the context for youth to achieve the following goals:

    ; To utilize the crisis as an opportunity

    ; To build hope for the future

    ; To begin a transition in their self-perception as competent and successful

    ; To achieve a new view of themselves to allow for the ongoing discovery

    of more helpful, acceptable, and successful behaviors

    ; To develop a treatment frame that marks the admission as the beginning of

    this transition

    ; To reframe life experiences from negative to positive

    The narrative clinical clusters establish a more consistent isomorphic relationship between the staff culture and the client culture by reminding the staff members of the uniqueness of each youth, the concept of equifinality, the functionality of the behaviors, and treatment pathways that are built on strength, capability, and hope. The narrative clinical clusters provide the staff with a framework that increases their capabilities which facilitated their ability to see the strengths and capabilities of the youth. The negative, acting-out behaviors become an opportunity to provide treatment rather than another problem to be controlled or eliminated.

     The following narrative clinical clusters were identified for the Crisis Care program:

    1) Attempts to gain control through power

    These youth are described as bullies who use physical and verbal intimidation of peers and staff to gain a sense of control. They are strong willed and oppositional with little respect for rules or adult expectations. They tend to be physically large for their age. Verbal fronting, laid back posturing, and cocky attitude are the non-verbal communication of their “I’ll do what I want and

    you can’t do anything about it” presentation. Their hopeless and fatalistic view of the world often has been formulated by being victims of abuse and/or observing violence within the family. They resist attachments to protect from the pain of multiple placements. They place themselves in dangerous situations to demonstrate their control over their life.

2) Sadness at the loss of hope

    These youth are described as followers. They are passive and lack energy, but will align themselves with those they perceive to have power. They visually and verbally demonstrate their low self-esteem. They want to belong and want to be protected. To this end, they attempt to buy friends through acting-out for those who control through power as well as through giving away their clothes and possessions. These youth have little concern for their personal safety when they follow others. These youth gain energy from following those they perceive to be in control.

3) Manipulate to achieve desires

    These youth are described as slick, smooth, con artists, and sociopaths. They always seem to have a hidden agenda. They are articulate, personable, and charismatic and get peers to distract and deflect attention away from them. These youth say the right things and seem more comfortable talking with adults than peers. The more friendly, talkative, energized they are, the more likely they are to soon behave in a manner that is against the rules. They always have an explanation or excuse for their behavior and they minimize the frequency and seriousness of past problems.

4) Pseudo-adults recreating family dynamics

    These youth most often come from single-mother homes with current or recent past boyfriend or step-father. They are often seen as unruly or truants, but the theme is “who is in charge?”

    Mothers have either taken a laissez-faire approach or have parented through intimidation. Often these youth have been given adult responsibilities i.e. caring for younger siblings, caring for incompetent parent, caring for ailing grandparent, or running the household. Parents and youth may be “best friends.” The parent elevates the youth to adulthood by giving adult responsibilities, but then pushes the youth back to age-appropriate or younger restrictions and the youth rebels.

5) Youth with unusual or bizarre behaviors

    These youth generally are identified as having behaviors that result from mental health issues or mental retardation/development disabilities. They may exhibit suicidal, psychotic, unusual, or weird behaviors. They are often shunned by the group or may be protected by the more aggressive peers. Their problems may be complicated by organic or neurological factors. Parents of these youth often are themselves limited. The youth are very needy and require constant one-on-one supervision.

6) Youth with substance abuse issues

    Youth in this group have a wide range of alcohol or other drug use that runs from recreational

    to addictive. Most feel hopeless and are victims of sexual abuse. Many are self-medicating to

    mask depression or diagnosable mental health disorders. They are high truancy risks due to

    addiction/dependency and are in more danger due to willingness to exchange sex for drugs.

7) Youth preoccupied with sexual issues

    These youth have been victims of sexual abuse. Their behaviors include consensual sex play

    with peers, promiscuity with peers and adults, offending and sexual assaults, sexual talk, and

    sexualized relationships. Some may have sexual identity issues. Many of these youth have

    lost family relationships due to the disclosure of sexual abuse and some are involved in legal

    processes that further isolate them from family. Drug and alcohol use is more recreational or

    self-medicating and is secondary to the affects of the sexual abuse.

    Outcomes and behavioral ratings were developed for each cluster to provide a

    continuum from the most negative behaviors to those positive behaviors that were

    inconsistent with the presenting problems. The purpose of developing the outcome and

    behavioral ratings was to establish an expectation for change. The targeted outcomes

    also provide a shift from looking at the problem to a focus on solutions and possibilities.

     Example: Outcomes &

    Behavioral Ratings

    Attempts to gain control through power

1) Working towards positive, attainable goals

I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

; Identifies long term goals ; No goals

    ; Identifies steps to achieve goals ; Pleasure seeking

    ; Evaluates progress ; No connection

    ; Assessed interests/aptitude between goals and actions

    ; Identifies strengths and weaknesses ;Focus on here and now

    ; Delays gratification ; Low frustration tolerance

2) Projects positive image

    I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

; Dresses for the occasion ; Provocative dress

    ; Use of make-up tasteful ; Excessive make-up

    ; Civil language in tone and word ; Profanity

    ; Groomed hair ; Poor hygiene

     ; Unkempt hair

3) Accepts responsibility for behavior

    I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

; Realistic view of consequences ; Blames others

    ; Accepts consequences ; Consequences unfair

    ; Understands how their behavior ; Challenges consequences

    affects others ; No self control over

    ; Empathy with victims behavior

    ; Retaliates, revenge, pay-

     backs

4) Builds trusting relationships

    I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

; Risks sharing feelings ; Hides/denies feelings

    ; Honest and direct communication ; Words and behavior do

    ; Keeps commitments not match

     ; Gossip, indirect

     communication,

     triangulates

5) Follows adult and societal expectations

    I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

; Follows home, school and probation rules ; Violates the rights of

    ; No criminal/delinquent behaviors others

    ; Sense of right vs. wrong ; Illegal/delinquent behavior

    ; Respect for authority ; Truant home, school and

     placement

    ; Feels rules do not apply

    to them

    6) No use of verbal or physical aggression

    I_____I_____I_____I_____I_____I_____I_____I_____I_____I_____I

     Very Well Moderately Equally Well Moderately Very Poorly

     Well Poor

    ; Positive conflict resolution ; Intimidates others

    ; No physical aggression ; Hits, fights, hurts others

    ; Demonstrates self control ; Verbal threats

    ; Uses activities to discharge (-) energy

    “Child welfare agencies nationwide struggle to identify risk factors and develop programs to deter youth from running away from substitute care placements…” (Courtney, et al, 2005). “Youth in substitute care are particularly vulnerable, as they

    have already experienced a disruption in living arrangements stemming, in the majority of cases, from documented abuse or neglect” (Courtney, et al). Rosemont’s Crisis Care program had a significant sub-group of youth who were recurring truants from treatment programs. A supplemental narrative clinical cluster was developed for those female adolescents who were prone to truancies with the following clusters identified:

    ; Family Loyalty (Run to…)

     Polarized thinking: “ If I do well in placement I am disloyal to my family.”

     Need to check on family safety.

    ; Flight from Discomfort (Run from…)

     Escape from emotional pain, i.e. anxiety, depression

     Escape from fear of unknown, i.e. future, emancipation

     Escape from placement discomfort, i.e. intimacy, interpersonal conflict,

    consequences

    ; Vulnerable Due to Sexual Abuse (Run to…)

     Need for love, affirmation

     Need to gain control

     Continued victimization

    ; Rules & Power Struggles (Run from…)

     Previous rules have been source of pain.

     History of pseudo-adult roles

     Testing of caregivers’ commitment

    ; Addictions (Run to…)

     Self-medicating

     Addiction primary issue

    ; Tag-a-longs (Run to…)

     Need to belong to peer group

     Need for excitement

     Hypotheses, treatment frames, and interventions were developed for each of the

    clinical narrative clusters for the Youth Who Run subgroup.

     Example: Hypothesis, Treatment Frame & Interventions

    FAMILY LOYALTY CREATE FAMILY VISITATION/PLACEMENT

    Hypotheses & Frames:

    ; Worried about a family member that is perceived to be more vulnerable (younger sibling

    at risk of abuse/neglect; depressed, suicidal parent; buffer to domestic violence; distracter

    from parental AOD use) “You are a very loving and caring daughter to risk yourself to make

    sure your family is safe. Now that you’ve let us know about your worries, can you allow

    adults to take over this worry for you? How can you be helpful to your family in other ways

    that allows them to focus their energy on the problems that you are so worried about?”

    ; Forced choice family loyalty is challenged by the placement; lack of parental sanction

    for placement; truancy usually immediate or following periods of success in placement. “I

    know you would rather be with your family. Right now you can’t be with them due to (state

    specific problem)(court order)(Protective Services). Would your family be relieved to know

    that you are safe here so they can take care of the business of getting you back home?” To

    parent(s): “I know if you had your way, your son would be home with you today. Is it alright

    with you that he is here, where you know he is safe, while you convince (court)(Protective

    Services) that he should be at home? How can he help you while he is here?”

    Interventions:

; Increased services for extended family expand the system.

    ; Increase communication and links with siblings/family. Don’t place barriers in attempt to

    “protect” the youth from family’s reality.

    ; Build connections with other natural supports: extended family, peers, mentors, church, and

    school.

    ; Facilitate the family giving sanction to the placement: “I know that your first choice would

    be to have your son home with you. But, right now that’s not possible due to protective

    services/Court/ homelessness, etc. Can you let your son know that it’s OK to be here and that

    the best way to be helpful to you is for him to do well so you don’t need to worry about him.

    That would be one way for him to help you have the time/energy to focus on things you need

    to do to convince the courts that he should be home with you.”

    ; Do not criticize the family do not agree with youth who may be critical of family.

    ; Reframe parent’s motives.

    ; Develop life book that follows child. Be creative focus on family of origin, history,

    strengths, research origin of last name, research meaning of given name, take pictures of old

    neighborhoods/homes.

    ; Develop family “hopes and dreams”: “If your mother were here, what would she expect of

    you?” “On the day you were born, your parents must have had hopes and dreams for you –

    what do you think were their hopes and dreams for you?”

Group Interventions:

    ; Use photos to build group identity and help individuals stay connected.

    ; Group painting i.e. mural builds group identity in manner that is not competing with family.

    ; Leave a legacy as members leave, have a formalized way for them to share their wisdom

    with group members remaining

    ; Group scrape book

    ; Remembering Groups share favorite family memories

    ; Make pictures that represent the earliest memory individual can retrieve. The nature of the

    memory is diagnostic in terms of view of family. How far back do you need to go with

    reframes re: family functioning and intent?

    ; Individual or group collage of “perfect family” or “your family when you are the parent.”

    ; Research meaning of given name: “What does the selection of that name tell you about your

    parent’s hopes/dreams for you?”

    Since the implementation of the clinical narrative clusters, the program has experienced a significant reduction in staff turnover because staff members have more resources to effectively use “problems as opportunities.” As staff members have

    increased their level of capabilities, they are more able to help the youth see their potential, beginning the process of experiencing themselves in a more positive manner. Likewise, the program has experienced a reduction in the truancy events each year since the implementation of the clusters for youth who run. The preliminary assessment of the data indicates that the impact is not necessarily on the prevention of the first truancy event from the program, but on the reduction of subsequent truancy events. The narrative cluster provides treatment frames for helping the youth determine what they are attempting to accomplish through the truancy and assists them in finding more successful solutions.

    Process for Developing

    Narrative Clinical Clusters

    Gathered diverse Identified broad

    members of teamdescriptive categories

    Reviewed Guided descriptions Worked lists into and revised with questions: phrases and with original systemic and sentencesteamsolution focused

    Revised, refined Testedwith Identified outcomes descriptionswhole team& behaviors (+/-)

    InterventionsTreatment FramesHypotheses

     The above flow chart outlines the steps used in developing narrative clinical clusters. It is imperative that a broad range of staff members are involved in developing the narrative descriptions. It is equally important that the person facilitating the development of the hypotheses, treatment frames, and interventions has a clearly identified and agency-approved theoretical base from which to operate. As is obvious in the examples provided in this paper, Rosemont Center incorporated a family systems, brief, solution-oriented model as the theoretical basis for the development of the hypotheses, treatment frames, and interventions. The goal was not just to enhance the capabilities of the staff members, but to do so within the context of a theory base adopted by the agency leadership. The development of the narrative clinical clusters required a major investment of time outside of the daily routine, team meetings, and crisis management. The development process, however introduced new treatment concepts in a

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