Basic and Core Issues
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P
erhaps the most difficult set of guidelines to define concisely are those that are most basic and commonly observed.  We neither want to overlook something important nor pedantically list items that are so obvious that they waste time and energy. To keep this more readily readable, we have placed eight “basic” issues on separate pages linked to this page in addition to the issues we raise on this page. Toward the bottom of this page, we address the need for protections so that students/clients will not be abused and policies that might be controversial and viewed as potentially abusive by some will be fully transparent.

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FamilyLightsm is an educational consulting firm specializing in work with families with a young person with behavioral, emotional or psychological difficulties.  We offer in-depth personal guidance to families on a fee basis and free guidance on the internet. FamilyLightsm attempts to be fully objective and accepts no advertising nor referral fees.  

To put it simply, we expect services to be safe and effective, but as usual, the devil is in the details. This means that, where practical, programs should use evidence based procedures and research based best practices, although we don’t want research to become strait jackets.  Click on this sentence for guidelines regarding use and over-use of evidence based procedures and “best practices.”

Each school and program needs to identify and be able to explain clearly what it intends to achieve and how it intends to do that, both as a whole program and with each individual client. Most schools and programs discussed in this website are about change.  This means that each school or program should be able to explain its process of change (or other goal if "change" is not appropriate) overall. It also needs to be able to explain how it assures that as individual needs vary, it ensures that it is addressing change appropriately with each individual. Generally, this requires having and individual treatment plan or service plan that includes measurable goals or more general goals that lead to measurable objectives. What is not covered in individual plans should be covered in general policy statements or published curriculum. How a program deals with change must be information it is willing to share with families and referral sources.

Schools and programs that profess an ability to  work with challenging populations need to be prepared to deal with the challenges that implies.  They need to be very clear about exclusionary criteria and attempt to screen out those populations who are likely to be outside their ability to serve.  They need to be committed to those students / clients who inconvenience the facility by acting out in ways that were known to be at risk at point of admission, and that the client and family and referral source reasonably expected would be within the scope of what the facility could deal with.  We happily make an exception in those cases in which a facility makes a conscientious effort to meet the needs of a student /client, then discovers they are not the best placement – then continue to retain that student /client for a reasonable time while a search for a better placement takes place. Of course, we understand the position of facilities that exclude following having been deceived by data received at time of admission.

Examples of facility behavior at variance with this, are two polar opposite situations.  We once referred a young adult with multiple problems, included but not limited to substance abuse, bipolar disorder, extreme immaturity, and entitlement run amok, to one of the most sophisticated (and expensive) psychiatric RTCs in the county.  The week before Christmas, he was precipitously discharged. (If we recall correctly, we were given 24 to 48 hours to find another place.)  Stated reason: the young man’s outrageous behavior (and we agree that it was outrageous) was an emotional threat to other patients.  The specificity with which they stated that he needed to be out by the weekend leading into Christmas, and other comments led us to believe that with the holiday coming up they did not have the staff to separate him from the other population (we agree that other population should not have needed to be exposed to his behavior).  We also think that when the situation became challenging, they simply did not choose to deliver the level of service the young man’s parents were paying for.  While the facility did not explicitly say they would retain this young man if he were to act out as he did, we think it is implied by their claimed level of sophistication that they would do so. Around our office, we now are fond of commenting that this facility is programmed to deal with the kinds of (fictional) patients who appeared in the Bob Newhart show of a few years back.

On the other hand, we could share multiple tales of programs “philosophically opposed to medications” which discharged kids for acting out behaviors that suggested a need for medication review and medication support along with the therapy of the program. One such program made a point of affirming its willingness to cooperate with managed care as an inducement to gain an enrollment, then absolutely refusing to cooperate when managed care made clear they would not further support treatment in that facility if there would not be a medication review.  We think both situations are morally equivalent to willful misrepresentation to gain an admission. 

We do not believe it is appropriate for any school or program focused on behavioral correction or healing to prohibit use of psychotropic medications unless all admissions are screened by a psychiatrist who limits admissions only to students for whom medications clearly will not be needed. To do otherwise is to lay the groundwork for denying people necessary care.

We expect schools and programs that are about change to understand the issues raised by the research on stages of change that has led to what is sometimes called the "Transtheoretical Model: or simply "The Stages of Change" approach.  We also expect that consideration will have been given to "Motivational Interviewing."  For discussion of these two concepts, click on this sentence.   We do not insist upon full literal incorporation of either concept in all cases, but we do believe people offering services directed to behavioral change in our time should have considered the applicability of these methods to what they are doing and to have not fully applied them for specific explainable reasons other than, "we never did it that way," or "we don't have the time to read that stuff" or “what we are doing now has worked for us for the last forty (or twenty or ten) years.” 

Research shows that quality relationships are the single most effective predictor of a successful outcome. (We expect to post references in 2009).  Nothing prompts a positive relationship between a difficult teen and an adult as fast as the adult approaching the teen with respect even while holding fast to very firm we want to see all schools and programs act on the principle that development of quality relationships is the most important factor successful outcomes.  We don’t see this as optional. This is an area where we see a significant lack of consistency with this guideline – and see utterly no excuse for that.  Our detail on this issue is on a separate page, but that does not mean we see it as unimportant.

It is of deep concern to us that it is almost impossible to find quality clinical programs that are not in any operating from an assumption of correcting bad or oppositional behavior. We want to see programming with appropriate clinical services -- including at times very intense clinical services -- where we could comfortably refer young people who are not oppositional  but simply need help with a clinical issue. 

We believe that such a facility would build on strengths that the students / clients bring with them, and avoiding gratuitous confrontation and approaches that seem based on a presumption of oppositional or anti-social behavior and carring a flavor of “tearing down.”  We coin a new term for what we advocate:  “Positive Interventionsm.”   The tear 'em down" tradition arose at a time that traditional mental health approaches were failing with most adolescents and young adults in need of behavioral health services.  These methods were an important stop-gap method to reach people falling through the cracks at one time, but there is sufficient knowledge today that we need not be stuck in the twenty first century with methods that are unnecessarily painful and less effective than they might have been for many. 

In addition, we want to see staff of all programs leading by example.  Children, teenagers, and even adults tend to learn and be influenced more by what they see others do than what they are told.  Students and clients in schools and programs are guided more than anything else by what they see others do.  We see far too much “Do as I say, not as I do,” in programming.  We also see too much of programs lowering staffing standards for overnight, weekend, and holiday coverage.

We also put high priority on accountability.  Schools and programs need to be accountable to parents and referral sources. 

We want to see a basic respect for privacy.  While physical safety comes first, except in an acute care setting, and except for people on special precautions due to suicide risk, it is not obvious to us why any person should not have some brief time at least daily in complete privacy, secure from intrusions, in any residential or boarding situation. There need to be additional times where the person is away from intense interaction with others.  Where mental health is at issue we don't want people completely isolating themselves but a balance is necessary. 

Last but not least, when a school or facility describes itself as having a goal of change or healing, then the approach to that goal needs to be integrated.  That means that every staff person is working toward the goals of change or healing, with teamwork, common plan and purpose, and a formal networking structure in the staff to keep everyone working in harmony.  We see a legitimate place for schools that sometimes accept students who are in need of therapeutic support that do not have an integrated approach to change or healing, provided they don’t claim that is the purpose of their school and they diligently attempt to limit their admissions to students suitable for such a school.  

The mixing of privately funded and publicly funded students / clients calls for comment here.  Many educational consultants and parents automatically rule out paying privately for their family members to participate in a school or program that includes publicly funded students / clients.  To the extent that this is a class issue, we simply do not agree.  The cross cultural experience that arises out of exposing the over-privileged with the under-privileged can be therapeutically beneficial to everyone if well managed.   But schools and programs that are culturally involved with the public systems too often treat the funding source as customer and parents simply as an object for manipulation.  Too many of these programs expect referral sources and funding sources to ally with them in face of legitimate concerns arising from parents, and will blunt criticism by manipulating the therapeutic approach to create the impression that the criticism is a manifestation of parent pathology.  In the future we will be addressing this issue aggressively.  We do know some very refreshing exceptions.   Particularly, as exceptions where we have had good experience, we call attention to Wediko School and San Marcos Treatment Center’s Prescription Plan.  We address this issue further in our page on accountability.

We also want to address the issue of transparency regarding over-all proper conduct with students/clients.   This points to two issues:   (1) The ability of people in schools/programs to communicate with the outside world.  (2) Clear policies available upon request regarding any of the kinds of procedures that have led to the entire profession and industry of special needs schools being accused of being abusers -- and a clear statement of why such policies and procedures are perceived to be necessary. 

On item (1) the obvious remedy is to be sure that students/clients are free to communicate if they believe abuse is occurring.  The problem is that unlimited access to phones can lead to abuses and in some situations, such as wilderness programs, it just is not practical.  It is within our guidelines that students should have access to phone for purposes of reaching their parent or legal guardian (or, in the case of an adult, an external contact of choice) and the appropriate government regulatory or protective agency. However we know that to make that the unqualified standard is not consistent with orderly operation of a program.  Granted that allowance, we want schools and programs, to the extent that they do not allow this access in an unqualified manner, to state their access policy in writing in their promotional literature, on their websites and with us, when they respond to our questionnaire.  We would like to see state licensing authorities to require the same.  This document should also include a detailed explanation as to why these restrictions are necessary for the orderly operation of the program and ultimately for the benefit of all students/clients.  We want to see evidence that students are not subject to reprisal of any kind due to such complaints made in good faith. 

On item (2), really an extension of item (1) we want to see all practices of the kinds we have seen criticized as a basis for abuse of students/clients described and authorized in specific policy statements that also explain the need, as in the paragraph above.  These need to be made available in promotional literature, websites, on this website and we would prefer with licensing agencies that are willing to receive such documents.

Last but not least we expect programs to show evidence that they learn from mistakes and apply the learnings. 

The following are basic and core issues which are further described on linked pages:

        Process of Change

        Evidence Based Best Practice

        Relationships

        Positive Interventionsm

        Accountability

        Staff Example

        Development

        Service Integration

 

Also discussed on this page is the issue of for Treatment or Service Plan Guidelines, which appear under our Clinical Guidelines.

Checklist of guidelines:

Every program should be consistent with Best Practices and Evidence Based procedures as described above and subject to the qualifications above.

Every program should be prepared to provide a clear, concise, understandable description of its philosophy and process of change, as described in more detail in the above paragraphs.  The explanation should be understandable by a person who is not a credentialed clinician. If the explanation requires references to specific documents, those documents should be freely available for distribution.

Every school and program needs to recognize the importance of quality relationships as an agent of change. Further it needs to recognize that the people who have the greatest amount of time with the students/clients are the most important change agents.  Therapists/case managers/clinicians are important to guiding the process but schools and programs need to recognize that the relationships with those who have more personal contact with the students/clients are the more important catalysts of change. This recognition needs to be reflected in the manner in which the school or program operates. 

Every school, program, self help group, mutual help group, therapist, mental health professional, or other agent of change should actively and deliberately consider how The Transtheoretical Model and Motivational Interviewing could improve their work, they should employ both or innovations that go beyond those, where applicable.  When programs choose not to employ these methods, they should be prepared to communicate clearly and effectively their reasons for not employing these, giving evidence that they have considered them and decided otherwise for solid reasons.

When questioned, each school and program should be able to give concrete and significant examples of situations in which it modified policies and / or procedures, as a result of self evaluation. 

Feedback is invited. We will  publish selected feedback.  Email FamilyLightResponse@yahoo.com

Disclaimer: No  program review, no matter how positive, is a blanket endorsement. No criticism is a blanket condemnation.  When we express our level of confidence in a school or program, that is our subjective opinion with which others might reasonably disagree.  When we assert something as fact, we have done our best to be accurate, but we cannot guarantee that all of our information is accurate and up to date. When we address compliance with our guidelines, you need to remember that these are only OUR guidelines -- not guidelines from an official source.  We have also set the bar very high, and do not expect any school or program to be in total compliance.  It is not appropriate to draw a conclusion of impropriety (or even failure to live up to conventional wisdom) from our lack of confidence in a school or program or from less than perfect conformity to our guidelines.  Some will say we expect too much. Readers are responsible for verifying accuracy of information supplied here prior to acting upon it. We are not responsible for inaccuracies.

Last revised 3-15-09; minor edit 7-21-09

     
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